The Essex Skipper 2025 registrations

The member’s first and last Name

Member’s Current Age

Member’s date of birth

Parent/ Guardians first and last name

Parent/ guardians email address

Parent/ guardians phone number 1

Parent/ guardians phone number 2

Emergency contact name, number & relationship to the member.

If parent/ guardian is not available

Member’s address:

Please state any diagnosis of disability

Eg Autism, ADHD, Cerebral Palsy...

Does the member have any medical diagnosis

Eg epilepsy, asthma, dysphalgia..

Does your child carry emergency medication eg midazolam/ epipen

If so please state what it is

Please give a list of your child's regular medications and medication timings over a 24 hour period.

Information of member’s GP

GP Name and surgery address

It is the responsibility of parents/ guardians to ensure that any medication brought to clubs is in the original pharmacy packaging with visible pharmacy label stating the child's name, medication name, medication dosage, medication use by date. If the label is not visible or medication appears damaged the medication will not be administered. All medication must be handed directly to the staff member signing the children into the club and then signed over to the parent/ carer collecting the member at the end of the session.

Please give any information relating the member’s diagnosis relevant to their time at club sessions

Does the member have any allergies/ food intolerance?

If so please state what they are allergic to and if they are life threatening allergies, mild allergies or intollerance

Does the member have any religious/ ethical dietary requirements they require us to put in place for them?

Does the member display any challenging or risky behaviours? If so please state what the behaviours are, the frequency of the behaviour, if there are any known triggers and how you manage the behaviours.

Does the member consistently follow one step verbal instructions including safety instructions?

Do you give consent for the member to be included in photographs at The Essex Skipper, please note these may be used on social media, our website or on promotional material.

Do you give The Essex Skipper staff consent to administer emergency first aid to the member if required?

Do you give The Essex Skipper staff consent to seek medical attention for the member in an emergency?

Please state if the member needs any assistance in regards to personal care

Eg the member wears pads/ needs prompting to use the toilet / none required

Do you give consent for the member to access local community activities during their sessions supported by The Essex Skipper staff?

Do you give consent for the member to access local community activities during their sessions independently not supported by The Essex Skipper staff?

Do you give consent for the member to travel using our Butterflies minibuses?

During trips and local activities members may wish to use park, soft play equipment or take part in outdoor pursuits/ water sports. Do you give consent for the member to use this equipment/ take part in these activities whilst in the care of The Essex Skipper staff and for the staff members to support the member to sign any waivers for the activities or sign on their behalf if required?

It is the responsibility of parents/ guardians or member themselves to ensure that the member is already wearing sun protection on the arrival for activities with The Essex Skipper. The Essex Skipper staff are not responsible for administering sun protection for members.

It is the responsibility of parents/ guardians of the member themselves to ensure that the member is already wearing weather and activity appropriate clothing on the arrival for activities with The Essex Skipper. The Essex Skipper staff are not responsible for ensuring the members are wearing appropriate clothing and can only verbally prompt/ advise suitable options.

Please upload an image of your child’s Nimbus Disability Access card.

If your child does not yet have one, you can apply here: https://app.accesscard.online/apply/access-card

What are the members main interests?

What activities are you most interested in for your child at Butterflies Club

What areas are interested in for the member at The Essex Skipper

The Essex Skipper will create a database of the data included in this form which will be password protected, with staff having the ability to access the data prior to the member attending sessions and within the sessions the member is attending to ensure they have all the correct information to provide the level of care required.

Form

The Essex Skipper Registration Form