Playscheme application form

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This playscheme application form needs to be completed once a year and can be used for multiple playschemes throughout the year. Please complete this form as thoroughly as possible to ensure we can put the right support in place for your child before they attend our playscheme.

If you have any difficulties completing this form online, please get in touch with us. We’re happy to post you a paper copy or send it through to you in an alternate format.

What to expect

We normally start taking bookings 2 months before each playscheme. On average we offer families a booking period of at least a month to complete and return their forms.
Any applications we receive before the closing date will be allocated a place on playscheme.
If we are over-subscribed we may not be able to offer you all the dates you have requested.
Following the booking period, we will allocate places to families and send out a confirmation letter detailing the dates you have been given and further information about how to pay.
Following the closing date and places being allocated, we will then offer places on a first come first served basis. We will operate a waiting list once the playscheme is full.
You will need to re-apply for a place on each playscheme – so if you attended or were on the waiting list in April, you will need to complete a new booking form if you want to attend in the summer.

Childs details

Name:*

First Last

Date of birth:*

Day

Month

Year

Gender:*

Address:*

Street Address Address Line 2 City ZIP / Postal Code Country

School:*

Does your child have an Education Health Care Plan (EHCP)?*

Yes

Parent / Carer details

Name:*

First Last

Relationship:

Address:*

Street Address Address Line 2 City ZIP / Postal Code Country

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 playscheme.

Emergency contact 1

Name:*

First Last

Relationship:*

Contact number:*

Emergency contact 2

Name:*

First Last

Relationship:*

Contact number:*

Health and medical information

How would you describe your child’s disability?*

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

If yes we may contact the school nursing team for up to date advice

Does your child have any allergies?*

E.g. food, animals, pollen, grass etc.

Please list what medication your child takes, the dose and times given.*

If your child has complex medical needs please contact us. If your child requires regular medication, we will contact the school nursing team to get up to date advice around this.

Communication needs

What form of communication does your child use?*

E.g. Verbal, PECS, BSL, Makaton.

Does your child have any needs in relation to your hearing or sight?*

Toileting

Does your child require assistance using the toilet?*

What assistance is required – incontinent, pads, pullups, needs prompting, needs help with wiping, hoist etc.

Diet

Does your child have any special dietary requirements? e.g. puree diet, thickener in drinks – what consistency, halal etc.*

If your child is PEG fed please contact the center when you submit your form as we will need time to arrange training for this.

Does your child need any help or supervising with feeding? How much does your child eat at lunch time and how can we encourage them to eat?*

Travelling and trips

Does your child use a wheelchair? If yes, do they need to travel in their wheelchair or can they transfer to a seat?*

We may have trips to public places. Is there anything we should be aware of when taking your child out?*

e.g. disability buggy used, visual support required, daily timetable to be used, no road danger etc.

Behaviour and support

If your child exhibits any challenging behaviour how is this managed?*

If your child becomes upset how do they like to be comforted?*

Does your child ever injure themselves or others? How do you de-escalate this? Are there any warning signs that we should be aware of?*

Does your child require any 1:1 care? If so when and with what specific tasks?*

In the event of a fire alarm will your child require any extra assistance?*

Is there anything specific we need to say or do in the event of a fire alarm. If we need more information regarding this we will complete a Personal Emergency Evacuation Plan with you for your child.

Likes and dislikes

What kind of activities/ toys does your child like?*

What activities do they not like? Is there anything that might upset them? E.g. loud noises, bright lights*

Are there any particular phrases we should use with your child e.g. now/ next. Are there any phrases that may cause upset or set off a crisis?*

Please provide any further information – which will help us to ensure that your child’s needs are met during their time at playscheme.*

Consent

Consent*

I hereby certify that the information given on this form is correct, and I have parental responsibility/delegated authority for this child- I give my permission for playscheme staff to:

Administer first aid if needed?*

Yes

To seek medical advice or treatment?*

Yes

To take trips outside of the playscheme building e.g. local park?*

Yes

To contact my child’s school/school’s nursing team?*

Yes

Signature:*

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 Playschemes?*

Behaviour management policy

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.
We understand that children and young people with additional needs sometimes experience the world and those around them differently and this can affect their responses. Our aim is to support them in responding appropriately to situations and to help them behave in a way that promotes enjoyment of the activities for them and those around them.
We will work with parents/carers to understand how their child behaves and the different behaviours that they can exhibit when upset, anxious and happy.
All staff and volunteers will be made aware of any particular triggers to behaviour that might be difficult to manage and techniques for de-escalating challenging behaviours.
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.
Parents/carers will be consulted as a situation develops in order to prevent the child/young person needing to be collected if possible.

Consent*

I have read and understood this behaviour policy

Signature:*

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

Parent/guardian/family member of service user

Leeds Mencap employee

Leeds Mencap volunteer

Other

If you're a service user or family member, please let us know which service/s you attend:

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.

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.

Please add how you agree these can be used (please tick all that you agree to)

Service user records such as a child’s development record, a one page profile or a care/support plan

In another service users record (as a group) such as a child’s development record, a one page profile or a care/support plan

In displays within Leeds Mencap premises inc Jimbo’s Community Nursery

On the Leeds Mencap’s and Jimbo’s Community Nursery website and social media (i.e. Facebook/Twitter/YouTube/LinkedIn)

In Leeds Mencap’s, Jimbo’s Community Nursery newsletters, leaflets and other publications

In publicity and fundraising features in the press (e.g. newspapers/radio/TV)

In fundraising literature (e.g. Thank you cards for donors, collection boxes, posters for events)

Funding applications and reports to funders (these are generally not in the public domain)

To use your first name alongside images and stories

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.

Name of consent-giver:

First Last

Signature:

Contact phone/email:

Date:

Day

Month

Year

Equal opportunities and monitoring

Please state the type of disability your child has:

Specific learning difficulty (SPLD)

Moderate learning difficulty (MLD)

Severe learning difficulty (SLD)

Profound & multiple learning difficulty (PMLD)

Social, emotional and mental health (SEMH)

Speech, language and communication needs (SLCN)

Hearing impairment (HI)

Visual impairment (VI)

Multi-sensory impairment (MSI)

Physical disability (PD)

Autistic spectrum disorder (ASD)

Other difficulty / disability (OTD)

SEN support but no specialist assessment of type of need (NSA)

Please state your child’s ethnicity:

One page profile

Name:*

First Last

Upload a photo of your child

This will only be displayed in the staffroom to aid with staff briefings at the start and end of each day.

Max. file size: 512 MB.

I like:*

I don't like:*

How I like to be supported and how I communicate:*

My goal on playscheme is:*