Super Sibs registration form

Siblings Group Registration Form

Step 1 of 7

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Childs Details:

(child who will be attending the siblings group)

Name:

Date of birth:

Day

Month

Year

Gender:

Address:

Street Address Address Line 2 City ZIP / Postal Code

Religion:

School:

Parent / Carer Details:

Name:

Address:

Street Address Address Line 2 City ZIP / Postal Code

Email:

Home Telephone:

Mobile Number:

Emergency Contact Numbers

In the case of emergency we will look to contact the following people in order. Please make sure that mobiles are switched on and contacts available during the session.

1:

Name:

Relationship:

Contact Number:

2:

Name:

Relationship:

Contact Number:

Support Information

Does your child have any medical needs such as epilepsy, asthma or other health related conditions?

Does your child have any allergies or dietary requirements?

Does your child have any mental health, behavioural or other support needs?

Information about the family:

Information about sibling with a disability:

Name of sibling:

Date of birth:

Day

Month

Year

Sibling’s disability:

Additional information:

Include information about parents/carers and siblings and the impact of having a disabled sibling on the child/young person who is applying to join the Siblings Group.

What support do you think your child would benefit from?

Tick all the apply

A chance to meet other siblings

To learn more about their siblings disability

Opportunity to speak 1:1 with a member of staff

Chance to share and hear other children’s experiences of having a sibling with a disability

Opportunity to have a break and have fun

Support with any caring role that they might have

Opportunity for trips out – bowling, cinema, meals out

Support them to have a positive view/ relationship with their sibling

Support with their own mental wellbeing

Consent Form

I hereby certify that the information given on this form is correct, and I have parental responsibility/delegated authority for this child.

Yes

I give my permission for Leeds Mencap staff to:

Administer first aid if needed?

To seek medical advice or treatment?

To take trips outside of the Vinery Centre e.g. bowling, park trip?

To contact my child's school.

Print Name:

Date

Day

Month

Year

Your details and contact from us

We will store your contact details on our database. Your child’s details will be stored confidentially. Please let us know how you would like to receive information from us. Please tick all your preferences.

General information – Including our newsletter, this may be information about our services and ways you can help, such as volunteering, how to donate to us or how you can get involved in activities like fundraising.

Post

Telephone

SMS Text

Service User information – Please also tell us how would you like to continue to receive information from us about accessing Leeds Mencap services and other services in Leeds.

Post

Telephone

SMS Text

How did you hear about Leeds Mencap Siblings Group?

• All children and young people and their families will be treated fairly and with respect. • We will support and encourage all children and young people attending activities to treat each other with kindness and respect. • Positive interactions and behaviour will always be rewarded and praised. • Children and young people will not be labelled, shouted at or told they are bad or stupid. • In all cases staff will use de-escalation techniques to try to calm or settle a child/young person or distract them with another activity. Physical intervention or restraint of a child or young person will only be used in exceptional circumstances. • If a child or young person’s behaviour escalates to a level at which they are at risk of harming themselves or others or they are distressed over a long period of time and are unable to settle and cannot be reassured, Leeds Mencap may ask parents/carers to collect their child/young person. • Wherever possible parents/carers will be consulted as a situation develops to prevent the child/young person needing to be collected if possible. • Electronic devices including mobile phones are not permitted at Youth Club. If a young person is seen to be in possession of any electronic device during the Youth Club session, they will be required to hand it in to a member of staff, who will store it in a locked cabinet for the remainder of the session. Electronic devices will be returned to Parents/Carers at the end of the session. • If a Young Person refuses to hand in their electronic device, Leeds Mencap Staff will call parents/carers to inform them of this and to request them to collect their child from the session.

I have read and understood this behaviour policy

Signed:

Date

Day

Month

Year

Images and stories consent form

Name of person(s) to be photographed/filmed/story shared:

This person is a:

Service user under 16

Parent/guardian/family member of service user

Other

If other, please specify:

Which service/s do they use?

For example: Siblings group, Activity groups

Consent

It has been explained to me that Leeds Mencap requires photographs, voice, video recordings and stories/case studies/quotes, in order to show a positive view of the organisation, its employees, volunteers and people that use its services.
Photos, videos and voice recordings might be used in children’s individual records, on displays in our building, on social media, in our publications, in funding applications and reports, on our website, publicity and advertisements for Leeds Mencap. In addition, our 3rd party supporters and funders may use images on their own platforms to highlight their support of Leeds Mencap.

I consent to all future collection, storage and use of photography, video, voice recordings and stories/case studies/quotes for myself/the above named person(s) (delete as appropriate) from the date stated below.

I agree

Please add how you agree these can be used:

To use your photographs, video, voice recordings and stories?

To use your first name alongside images and stories

By signing this consent form I agree to all of the below:

I understand that any images, recordings and/or stories/case studies/quotes may be used by Leeds Mencap at any time, both now and in the future. I/the named person(s) above will not benefit in any way as a result of being involved and I will not own the copyright.

Consent continues with no time limit, however, it is important that images and stories are up to date, therefore, we will not normally use images or stories for more than three years after the date that they were collected, unless there is a legitimate reason to use them beyond this date.
You can change or withdraw your consent at any point, if you would like to do this, please email our Administrator at info@leedsmencap.org.uk or call us on 0113 235 1331.

If you withdraw your consent for an image or story to be used, and this has been used for publicity materials, we will stop using these with immediate effect, however, we will not be able to withdraw publicity that has already been circulated. We will remove images from leaflets and publications and reprint following discussion with Fundraising/CEO.

We will also be unable to remove historic images from social media

I agree

Name of consent-giver:

Contact phone/email:

Date

Day

Month

Year

Please tick your Child's Ethnicity

White British

White Irish

Traveller of Irish heritage

Any other White Background

Gypsy/Roma

White & Black Carribean

White & Black African

White & Asian

Any other Mixed background

Indian

Pakistani

Bangladeshi

Any other Asian background

Black Caribbean

Black African

Any other Black Background

Chinese

Any other Ethnic Group

If any other ethnic group, please state which