Name of child with Special Educational Needs or Disability (cwSEND) *

First Name

Last Name

Gender *

Male

Female

Date of birth *

MM

DD

YYYY

Services interested in registering for: *

Coping with CHAOS

Project My Time (age 8+)

Awesome Nights (age 13+)

Name of parent/carer *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Does your child have a Statement/EHCP/LDA in place? *

Yes

No

Are you in receipt of direct payments? *

Yes

No

Do you have a social worker? *

Yes

No

Please read and confirm each of the following statements *

Privacy statement: Except as required by law, we will never share your details with other organisations to use for their own purposes. For full details see our privacy policy linked at the bottom of this page or please get in touch on 01202 718266.

I give permission for this form to be read by all Short Breaks staff looking after my child (named above) at any sessions they may attend.

Occasionally we take photographs at our sessions for fundraising, grant evaluation and publicity purposes. Please tick this box if you give your permission for Diverse Abilities to use moving and still images of your child(ren) on marketing materials, for example our website, social media, and printed items.

The information provided on this form will be help on a computerised database, registered under the Data Protection Act 1998. The information will solely be used for Diverse Abilities and will be disclosed only to those persons involved in the activities and our local authority funders. Please tick the box if you have read and understood this.

Please provide an image of your child *

We need this for our files as part of staff training, and it will never be shared outside of this purpose. Failure to do so will mean we cannot process your application.

I acknowledge that I must now email an image of my child to clare.rochford@diverseabilities.org.uk in order to complete registration.