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Walsall Centre- Weekend sessions- Booking form
Hi there, please fill out and submit this form to secure your child's place.
29
Questions
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1
What is your name?
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Parent/Carer Full Name
First Name
Last Name
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2
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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3
Phone Number
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Contact Number
Please enter a valid phone number.
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4
Please provide your Email address
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example@example.com
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5
What is your child's full name?
*
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First Name
Last Name
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6
What is your child's date of birth?
*
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Child’s Date of Birth
-
Date
Day
Month
Year
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7
Select the Days You Want to Book
*
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Which days would you like to book? Please select all that apply.
Saturday 6th June 1-6pm
Sunday 7th June 10-3pm
Saturday 13th June 1-6pm
Sunday 14th June 10-3pm
Saturday 20th June 1- 6pm
Sunday 21st June 10-3pm
Saturday 27th June 1- 6pm
Sunday 28th June 10-3pm
Saturday 4th July 1-6pm
Sunday 5th July 10-3pm
Saturday 11th July 1-6pm
Sunday 12th July 10-3pm
Saturday 25th July 1-6pm
Sunday 26th July 10-3pm
Saturday 18th July 1-6pm
Sunday 19th July 10-3pm
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8
What school does your child attend?
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9
Does your child have any additional needs we should be aware of?
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10
Does your child have any allergies?
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please give details of allergy or type No if they do not have any allergies
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11
Does your child suffer from Epilepsy?
If yes you must provide us with a printed copy of their Epilepsy Care Plan
YES
NO
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12
Is your child new to Our Special Angels?
*
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If yes you will receive an email with the 'All About me form'. Please complete this with as much detail as possible and bring it with you to the first session.
YES
NO
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13
Does your child require medication to be administered while they are with us?
If yes you will receive an email containing a medication consent form. Please complete this and hand it to our First Aider on site
YES
NO
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14
Do you give consent for pictures to be taken and shared on the parents’ WhatsApp group?
*
This field is required.
YES
NO
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15
Can we use your child’s photo on our social media platforms?
*
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YES
NO
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16
What are your child's personal care needs?
*
This field is required.
Independent
Independent but needs help washing
In nappies – changed by 1 person
In nappies – changed by 2 people
Hoisted – by 1 person
Hoisted – by 2 people
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17
Is your child PEG fed.
*
This field is required.
PEG fed" refers to feeding a person through a Percutaneous Endoscopic Gastrostomy (PEG) tube, which is inserted into the stomach. If yes you will receive an email containing more details.
YES
NO
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18
How will you be paying for your child’s place?
*
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Payment type
I will be paying privately (£100 per session)
I will be using Student Finance
I will be using Tax-Free Childcare
I will be using Childcare Vouchers
I will be using my childcare element from universal credit
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19
Please provide the email address of the agency who will be covering the cost.
*
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20
Total to pay
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21
Please confirm.
*
This field is required.
I understand that payment must be made in advance of sessions. I agree that payments are non-refundable unless I cancel by 5:00pm on the Thursday before my child’s session (UK time). I understand cancellations after this deadline are non-refundable.
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22
Please confirm.
*
This field is required.
I understand and agree that if I am contacted to collect my child early due to being significantly dysregulated, in distress, or at risk of harming themselves or others, no refund will be issued for the session. This is because staffing costs remain the same, as staff are still required to be present and paid for the full session.
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23
Please provide an emergency contact (1)
We’ll only get in touch with the emergency contact when we are not able to get through to you
First Name
Last Name
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24
Relationship to child
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25
Emergency contacts telephone number (1)
Please enter a valid phone number.
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26
Please provide an emergency contact (2)
We’ll only get in touch with the emergency contact when we are not able to get through to you
First Name
Last Name
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27
Relationship to child
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28
Emergency contacts telephone number (2)
Please enter a valid phone number.
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29
Todays Date
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Date
Day
Month
Year
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