Y - Connect - Enrolment Form
Child Information
Name
First Name
Last Name
D.O.B
-
Month
-
Day
Year
Date
Gender
Ethnicity
Does Your Child Attend Nursery
Name of Nursery
Primary Language Spoken at Home
Diagnosed Conditions
Are there any current concerns about your child’s development or behaviour (Yes/No) If yes, please describe:
Address Of Child
Street Address
Street Address Line 2
City
State / Province
Postal Code
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Parent / Carer Info
Name
First Name
Last Name
D.O.B
-
Month
-
Day
Year
Date
Phone Number
-
Phone Number
Relationship To Child
Gender
Ethnicity
Email Address
Address
Street Address
Street Address Line 2
City
State / Province
Post Code
Emergency Contact (Name and Phone No)
Emergency Contact (Name and Phone No)
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Health and Safety Info
Does your child have any allergies? (Yes/No), If yes, please specify:
Does your child have any medical needs or take any medication regularly?
Are there any sensory sensitivities we should be aware of (e.g., lights, sounds, textures)?
Is there anything that helps calm or comfort your child during distress?
Do you or your child have any accessibility needs?
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Session Expectations
What are your main goals for attending these sessions? (e.g., socialisation for us both, sensory play ideas, bonding time)
Is there anything you hope your child will gain from this experience?
Is there anything you hope to gain as a parent/caregiver?
Consent
I give permission for my child to participate in sensory session (Yes / No)
I give permission for photos/videos to be taken for documentation or promotional purposes (anonymised where required). (Yes / No)
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: