Activities Unlimited Additional Information Form 2016 Please attach a It is important to provide as much information as possible, to ensure your passport size child’s enjoyment and safety. photo here if possible We may need to share this information with other organisations if they are providing care for your child/young person.
FIRST NAME (and any nickname used)
SURNAME
DATE OF BIRTH AGE
SCHOOL / COLLEGE
PARENT / MAIN CARER’S NAME
HOME ADDRESS
POST CODE
CONTACT DETAILS Email:……….………………………………………….………………
Home:...... …...... ………......
Work:...... …….……...
Mobile:...... ……..……....
EMERGENCY CONTACT Name: …………………………………………………………………
Named person Relationship:………………………………………………………… to be reachable at all times during activity Tel No’s:..……………………………………………………………..
Mobile:..……………………………………………………………….
GP SURGERY Name:………………………………………………………………….
Address:………………………………………………………………
Tel no:…………………………………………………………………. HEALTH AND MEDICAL NEEDS DIAGNOSIS
Please describe your child’s condition or disability…
MEDICATION
What medication, if any, does your child take regularly?
Will he/she need to have Yes If yes - at what times of the day? this medication during the activity day/weekend? No
(delete as applicable)
Does your child have any Please include full details and attach a Care Plan if appropriate: major health needs that staff should be aware of (e.g. epilepsy, asthma, severe allergies etc…)?
…or are they technology dependent?
Does your child need to have any emergency medication available at all times? e.g. Inhalers, epipen, epilepsy medication etc...
If YES please describe
Are there any activities that your child should not take part in for medical reasons? e.g. Swimming, trampolining, martial arts etc…? PERSONAL CARE AND HYGIENE NEEDS Does your child: (tick as appropriate) Please give more information… a. Manage own personal care independently? b. Need encouragement or support for personal care? c. Need practical help with care? e.g. pads changing / cleaning up? d. Need to use a hoist and changing bed? e. Girls: does she cope independently with menstruation or need help?
MOBILITY Does your child: (tick as appropriate) Please give more information… f. Walk independently? g. Use walking aids? h. Use a wheelchair: 1. Occasionally? 2. Permanently? i. Use an electric wheelchair?
MEALTIMES j. Does your child: (tick as appropriate) Please give more information…
k. Manage mealtimes independently? l. Need supervision or practical help to manage food? m. Does your child have any dietary needs relating to serious allergies or medical conditions? Eg no nuts, gluten free diet? Please give details…
COMMUNICATION AND SENSORY NEEDS Does your child: (tick as appropriate) Please give more information… n. Have a sensory impairment? (Sight, hearing etc…) o. Have good verbal skills? p. Use other methods of communication eg BSL, Makaton, Communication aid, PECS? BEHAVIOURAL AND EMOTIONAL NEEDS Identify possible triggers and risks, and describe Please answer Yes or No… strategies to manage behaviour. Please give as much information as possible. If necessary continue at the bottom of the page or overleaf… a. Is your child’s behaviour generally reasonable for their age? b. Can your child be managed in a small group of 3 – 4 children? c. Does your child usually need constant supervision?
SPECIFIC RISK AREAS d. Is your child likely to wander or run off? e. Is your child aware of danger? e.g. water/heights/traffic?
Describe specific concerns f. Does your child have any strong fears? (balloons, dogs etc...)
Please specify fears… g. Does your child have temper tantrums or other strong reactions?
If yes, to what? h. Is your child sexually aware?
If so, does he/she need close supervision when around specific individuals or groups? i. If there is any more information that would be helpful for us to know, please provide details below or continue overleaf PARENTAL CONSENT
Name of child: ...... Date of Birth:……...... ……..
Activity: Thorpe Woodlands Adventure Centre
Date(s): …………………………………………………………………………………….
I consent to my child taking part in the activities. I acknowledge that the staff will be liable in the event of any accident only if they have failed to take reasonable care of my child during the activity.
I have read any information provided with regard to the standard of behaviour and /or code of conduct expected during the activity and I undertake to reinforce this information with my child.
Signed………………………………………………………………..….. Date………………………
Medical emergency I agree that staff should take any medical action deemed necessary in the event of an emergency.
Signed……………………………………………………………………. Date………………………
Sharing Information I give my consent to this information being shared with any organization that will be providing direct care for my child.
Signed…………………………………………………………………….Date………………………
Photographic consent
Please be aware that: During the course of our activities lots of photographs are taken by the young people themselves and by carers and staff to record the event and celebrate achievements. We actively encourage photographs as a means of communication with family and friends. Occasionally a TV film crew or press reporter may want to film or report an event that could be shown on TV or feature in the local press. Photographs may be used in displays about the activities/events, in Suffolk County Council publications, including AU News and on the Activities Unlimited website.
We will endeavour to ensure that photographs and film material from activities are used in a responsible and respectful manner.
Please sign below only if you DO NOT agree to your child/young person being photographed or filmed during activities and events organised by Activities Unlimited.
Signed:………………..…………………………… Print Name………………………………………….
Relationship to child / young person:………..………………………… Date …….…………………… Code of Conduct
We want all young people attending our activities to have a great time and feel safe. This means that we must ALL respect and support each other and help EVERYONE to feel a part of the group.
To make sure this happens, we have a few rules:
No Bullying Bullying includes name-calling, ganging-up, picking-on someone, keeping them out of the group, as well as physically hurting someone. You should not touch/kiss or get too close to someone in a way that makes them feel upset.
No Discrimination
This means we do not treat someone unfairly because of who they are – how they look, their disability, race, sexuality, clothes etc
Participation We expect everyone to try their best to take part in activities and give new things a go.
Respect When people find things difficult, we should encourage them. We should never laugh at someone who finds things hard. Responsibility We expect everyone to act sensibly and not to do anything that would cause danger to others.