No Barriers Foundation - Family Activity Registration Form - Children's Activity Service

No Barriers Foundation – Family Activity Registration Form – Children’s Activity Service

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Information

We are asking parents/guardians to share some information about their child’s preferences, interests and favourite activities, along with some information about their child’s diagnosis and needs. This will help us to better understand the activities your child may enjoy and benefit from. The information provided will help us to prioritise and match children to suitable activities, and to keep families informed about relevant opportunities as they become available.

What age bracket is your child currently in?(Required)

0-5 years old

6-12 years old

13-18 years old

Would you prefer your child to be part of..(Required)

Individual based activities only

Group based activities only

Either Individual or group based activities

Activity Preference 1(Required)

Activity Preference 2(Required)

Activity Preference 3

Activity Preference 4

Please suggest any other activities you would like to be considered for scheduling (if any)

Would you, as the parent/guardian, be interested in the following (tick all that apply)?

Parent psychotherapy group sessions (parent only care sessions)

Parent/Child Move & Sensory Play

Parent/child small group reflexology sessions

Parent/child small group play therapy sessions

Parent/child therapeutic support programme (connect & play)

Connect & Play Developmental Programmes(Required)

0-4 years – Supporting attachment, communication, play and early emotional development.

4-7 years – Developing emotional awareness, regulation and connection through play, stories and creative activities.

8-11 years – Supporting emotional awareness, confidence, friendships, frustration, problem-solving and communication.

12-15 years – Supporting identity, friendships, boundaries, confidence, communication and increasing independence while maintaining connection.

16-18 years – Supporting identity, relationships, emotional wellbeing, boundaries, decision-making, resilience and the transition towards adulthood

Parent/Guardian Information

Parent/Guardian Name 1(Required)

First Last

Parent/Guardian Name 2

First Last

Parent/Guardian Phone(Required)

Parent/Guardian Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Password(Required)

Enter Password Confirm Password

Strength indicator

Child's Details

Children's Disability Network Team (CDNT)(Required)

Child's Name(Required)

First Last

Gender(Required)

Male

Female

Prefer not to say

Child's Date of Birth(Required)

Please could you share some information on your child's diagnosis or additional needs?(Required)

Does your child have any medical conditions?(Required)

Yes

Please describe your child's medical condition(s)?(Required)

Please list any medication they take for this/these medical condition(s) if any?(Required)

Does your child have any allergies?(Required)

Yes

Please list your child's allergies?(Required)

Your Childs Developmental Profile

Helps our team support your child well. These are required – please write n/a if something doesn’t apply

What are your child's strengths?(Required)

Communication preferences(Required)

Using my words

Not yet using my words

Augmentative and Alternative Communication (AAC)

Gestalt Language Processing (GLP)

(i.e Pointing, Vocalisations, Gestures, Eye Gaze, Echolalia)

What kind of communication method is your child using, if any?

Device

Picture Cards

Objects of Reference

Other

(i.e Pointing, Vocalisations, Gestures, Eye Gaze, Echolalia)

Toileting Ability(Required)

Fully Toilet Trained & Independent

Toilet Trained But Need Support

Needs Full Support With Toileting

Other

Does your child experience dysregulation?(Required)

Yes

What dysregulates your child, if anything?(Required)

Lack of Sleep, Hungry, Thirsty, Feeling Sick or in Pain

Sensory (e.g seeking or avoiding sounds, touch, movement, Crowded areas etc .)

Separation from trusted care giver (i.e Mum, Dad, other)

Transitions & Change (i.e new people, new places, new activities etc.)

What does your child like to do to self regulate? (e.g. jumping, crashing, noise)(Required)

Anything else our team should know? (optional)

Consent

(Required)

I confirm I am the parent/foster parent or legal guardian of the child named above, and that the information I have given is accurate

(Required)

I give explicit consent for No Barriers to collect and use my child’s health and support information to keep them safe and supported during the programme.

(Required)

In-line with GDPR, I consent to my child’s information being collected and stored for 36 months for the purpose of gathering and reviewing expressions of interest, understanding my child’s preferences and needs, and supporting the development and planning of the programme. At the end of this period, the information will be securely deleted unless there is another lawful basis for retaining it. Information can also be deleted at any time upon request.

(Required)

In an emergency, where I cannot be reached in time, I authorise No Barriers staff to seek appropriate medical assistance for my child, including calling emergency services.

I consent to No Barriers taking photographs or video of my child during the camp for its records and promotion. I can withdraw this at any time