What Is the CAN Network?

Children with Additional Needs (CAN) Network Application Form Please email your completed forms to [email protected] Or post to: CAN Network LDD Service Highwood Annexe Fairwater Drive Woodley RG5 3RU

What is the CAN Network?

The CAN Network is an information and support service for children with additional needs and their families, in the Wokingham Borough. Based on the information completed in this form, the CAN Network maintains a statutory register which is used to help shape service provision.

Families who join the CAN Network can choose to apply for the following benefits (via this form)

 Monthly newsletter  A CAN Card, which allows your child to access concessions at leisure attractions and facilities  Information and Advice Sheets

The information you provide will be treated as confidential and will only be used statistically by other services. No identifying personal information will be passed to any other organisation without prior consent from a parent or carer. The CAN Network is not linked in any way to other statutory registers or databases. Please be aware that completion of this form does not mean that your child or family will automatically receive a service from any of the statutory or voluntary agencies.

Thank you for your time in completing this form. Please allow up to 14 days for your application to be processed. If you would like any further information or would like some assistance in relation to your child, please do not hesitate to get in touch with the CAN Network Co-ordinator . Should any of your personal information change, please contact the CAN Network.

Child Details First Name:

Surname: Gender: Male Female

Date Of Birth:

Parent/Carer Details First Name:

Surname:

Relationship to child:

Contact Details Address:

Telephone Number: Home:

Mobile:

Email address:

Religion:

Ethnic Background White – British Mixed – Wh/Blk Carribean Other Asian or British background White – Irish Mixed – White and Asian Black or Black British – Caribbean White – Traveller of Irish Mixed – Other Black or Black British – African Heritage White – Gypsy/Roma Asian or British – Indian Other Black or Black British White – Other Asian or British – Pakistani Chinese Mixed – Wh/Blk African Asian or British - Bangladeshi Other I do not wish an ethnic background to category to be recorded

Details of Additional Need Please tick all that apply. If your child does not have a specific diagnosis, please tick ‘other’ and give more details about their needs. ADHD (or ADD) Autistic Spectrum Condition : Autism Aspergers Syndrome

Blind/Partially sighted Cerebral Palsy Chronic medical condition (please give specific details) Cystic Fibrosis Deaf/Partial hearing Downs Syndrome Dyslexia Dyspraxia Epilepsy Global Developmental Delay Learning Disability: Mild Moderate Severe Muscular Dystrophy Physical Disability (please give details) Spina Bifida Other (please give details)

CAN Network Benefits Please select any of the benefits that you would like to have by ticking the relevant boxes:

Monthly Newsletter from the CAN Network A CAN Card, used to access concessions at leisure attractions and facilities. Please enclose (or email) a photo of your child (any size), which will be returned to you.

Information Sheets Early Years and Play Toilet Training Please select sheet for: Nursery Education Food and Feeding Autistic Spectrum Condition Sleeping Difficulties Starting Primary School Learning Difficulty Bullying at Primary School Moving to Secondary School Physical Difficulty Bullying at Secondary School Transition (from 14 years plus)

Information Sheets Angelman Syndrome Epilepsy ADHD Fetal Alcohol Syndrome Autistic Spectrum Condition Fragile X Syndrome Brittle Bone Diseases Guillain-Barre Syndrome Cerebral Palsy Hearing Impairments Challenging Behaviour Learning Difficulties Charcot-Marie-Tooth Disease Leighs Disease Cleidocranial Dysostosis Muscular Dystrophy Cornelia De Lange Syndrome Prader Willi Syndrome

Cri du Chat Syndrome Scoliosis Dandy Walker Syndrome Speech and Language Difficulties Down Syndrome Sturge Weber Syndrome Dyspraxia Tuberous Sclerosis Edward’s Syndrome Visual Impairment Ehlers-Danlos Syndrome West Syndrome Encephalitis Williams Syndrome Other (please specify)

Signature of Parent/Carer…………………………………………………..

Print name……………………………………

Date…………………………………………

Thank you for completing the form. The information will be held on a computer on a protected database. Under the Data Protection Act 1998, you have a right to see, update, or withdraw information held at any stage.