B&NES Groups Registration form.
Join us for a range of activities from cooking, to den building and movie nights. We support children and young people from 5-19 years old in the Bath and North East Sommerset area.
Are you a professional filling out this form on behalf of a parent/carer?
*
Yes
No
Name of professional
First Name
Last Name
Email of professional
example@example.com
Phone Number
Please enter a valid phone number.
Format: 00000000000.
Organisation/Service
I can confirm that I have received consent from the parents/carers of the child or young person I am referring to share the below information with the Out and About Consoritum
Yes
Child or Young Person Basic Information
Child or Young Person
Name:
*
First Name
Last Name
Child or Young Persons preferred name:
If different to their actual name
Does your child receive a Direct Payment from Bath and North East Somerset Council?
*
Yes
No
I don't know
Date of Birth:
*
/
Day
/
Month
Year
Date Picker Icon
What gender does your child identify as?
*
Male
Female
Prefer not to say
Other
Name of School
Ethnicity
*
Please Select
White - British
White - Irish
White - Gypsy (Including English, Scottish and Roma Gypsy) or Irish Traveller
White - Eastern European
White - Other
Mixed Dual Background - White and Black Caribbean
Mixed Dual Background - White and Black African (non Somali)
Mixed Dual Background - White and Asian
Mixed Dual Background - Other
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Chinese
Asian or Asian British - Other
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Somali
Black or Black British - Other
Other - Arab
Other - Iranian
Other - Kurdish
Other - Iraqi
Other - Turkish
Other
Prefer not to say
Type of Education
*
Mainstream
Special
Residential
Hospital
Other
Parent/Carer Basic Information
Parent or Carer
Name
*
First Name
Last Name
Relationship to Child or Young Person
*
Mobile Phone Number
*
Please enter a valid phone number.
Format: 00000000000.
Home Phone Number
Please enter a valid phone number.
Format: 00000000000.
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postcode
Does the family have access to a car?
*
Yes
No
Any parent/carer support needs/disability
*
Yes
No
Details on parent/carer support needs/disability
Emergency Contact Information
Emergency Contact Information
This should be a different contact to the parent/carer contact information added above
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: 00000000000.
Relationship to Child or Young Person
*
Permissions and Consent
Permissions and Consent
I give consent for my child to undergo emergency treatment if necessary
*
Yes
No
I give permission for photographs, videos and other recorded information of my child to be used in publicity materials, social media, websites for the overall consortium, consortium provider and Bath and North East Somerset Council
*
Yes
No
I give permission for my child to participate in local trips/off site activities.
*
Yes
No
To ensure the continued funding of our provision we must regularly update our funders with information about the children and young people we support. Please tick to indicate you give permission for the Out and About consortium to share information provided within the consortium and with Bath and North East Somerset Council.
*
Yes
No
I am happy for the consortium to send me newsletters and information
*
Yes
No
I will not send my child to groups/befriending if they or anyone they are in contact with has symptoms of Covid-19.
*
Yes
No
I give permission for my child’s school and/or Bath and North East Somerset Council to share my child’s EHCP with WECIL and the Out and About Consoritum Providers
*
Yes
No
Signature
I am signing this on behalf of the parent/carer and can confirm I have received consent to do so
*
Yes
Disability Information
Disability Information
Does your child have a social worker?
*
Yes
No
Social Workers Name
Social Workers Phone Number
Please enter a valid phone number.
Format: 00000000000.
Please indicate if any of the impairments/disabilities below are relevant to your child:
*
Autism Spectrum Condition
Mental/Emotional Distress
Challenging Behaviour
Physical Impairment
Sensory Impairment
Complex Health Needs
Deaf (BSL User)
Speech Impairment
Visual Impairment
Learning Difficulties (Mild)
Learning Difficulties (Moderate-Severe)
Long Limiting Illness
Prefer not to answer
Other
Please provide further details with regards to your child's needs below.
The more information you provide the better we will be able to identify appropriate support for your child.
Behaviour
*
Does your child present challenging behaviour?
*
Yes
No
Please provide further detail:
E.g. How is it presented? What are the triggers? Etc.
Communication (Sign, Makaton, Verbal, Non-Verbal etc.)
Individual Support Needs
Does your Child or Young Person require support with personal care?
*
Yes
No
Please provide further details where necessary:
(This can be pad changing, support with toileting, feeding, hand washing, changing clothing if they get wet/muddy/dirty Etc.)
Dietary Requirements
Does your Child or Young Person require support with eating or drinking?
*
Yes
No
Please provide further details where necessary:
Does your Child or Young Person Abscond?
*
Yes
No
Please provide further details where necessary:
Does your Child or Young Person have any phobias?
*
Yes
No
Please provide further details where necessary:
Please provide details of any religious or cultural requirements we need to be aware of:
Please provide further information you feel like we should know about your child or young persons needs:
Please upload any Care Plans etc. That you feel would be beneficial for supporting your child or young person.
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Children and Young Person Likes and Dislikes
Children and Young Person Likes and Dislikes
This is a chance for you to tell us what your child enjoys doing and what they really dislike, please use as much detail as possible so we can plan appropriate activities.
What does your child like/enjoy?
*
What does your child dislike?
*
Medical Information
Medical Information
Does your Child or Young Person have any Allergies?
*
Yes
No
Please provide details of their allergies:
Does your Child or Young Person have Asthma?
*
Yes
No
Does your Child or Young Person have an emergency inhaler?
*
Yes
No
Please provide any further details on their Asthma:
Does your Child or Young Person have Epilepsy?
*
Yes
No
Do they require Epilepsy medication?
*
Yes
No
Please provide any further details on their Epilepsy:
E.g. What type of seizures do they have? How are they presented? Etc.
Please upload any relevant Epilepsy Plans and/or Risk assessment's
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Choose a file
Please note if we do not receive your child's most up to date Epilepsy Plan we will not be able to accept them on the Holiday Provision.
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Are there any other medical conditions we need to know about?
*
Yes
No
Please provide further details:
Does the Child or Young Person take any medication?
*
Yes
No
Please provide further details:
Please provide further details on anything you feel like we should know about your child or young persons medical needs:
B&NES Groups Consent
B&NES Groups Consent
I give consent for WECIL to share any relevant information (care plans, documents, any concerns) with the school/ social worker / local authority named on the form, if it is in the best interests of my child or young person.
*
Yes
No
I give my consent that latex plasters can be applied as required by Staff?
*
Yes
No
I give my consent that non- latex plasters can be applied as required by Staff?
*
Yes
No
Where appropriate and needed, I give consent for staff at the service to carry out personal care support as detailed in the form above.
*
Yes
No
Signature
I am signing this on behalf of the parent/carer and can confirm I have received consent to do so
*
Yes
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