Youth Club application form

To apply for a place at Leeds Mencap 9-13’s or 14-18’s Youth Club you need to fill in this form.

Please complete the form as thoroughly as possible to ensure we can put the right support in place for your child before they attend Youth Club. If you need help filling in this form please contact us on 0113 2351331

If your child has medical needs or significant challenging behaviour please contact the Activities Coordinator on 0113 2351331 to discuss this further.

If the Youth Club you are applying for is currently full you will be placed on a waiting list and contacted when a place becomes available.

Step 1 of 15

Childs Details:

Name:

Date of birth:

Day

Month

Year

Gender:

Address:

Street Address Address Line 2 City ZIP / Postal Code

School:

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

Yes

Parent / Carer Details:

Name:

Relationship:

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:

Health and Medical Information

How would you describe your child’s disability? Do they have a diagnosis?

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. If YES, please tell us what they are allergic to, for example nuts and what food and drink they are not allowed. Please also give an indication of the likely reaction to exposure and the action we should take:

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 snack time and how can we encourage them to eat?

Behaviour and Support

If your child exhibits any challenging behavior 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?

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 Youth Club.

How did you hear about Leeds Mencap Youth Clubs?

Consent

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 Youth Club staff to:

Administer first aid if needed?

To seek medical advice or treatment?

To take trips outside of the Vinery Centre e.g. local park?

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

Print Name:

Date

Day

Month

Year

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. • If a child or young person has a behaviour management plan in use at school Leeds Mencap will ask to see the details, with the parents/carers permission, so that staff and volunteers can manage behaviour in a consistent manner. • 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.

I have read and understood this behaviour policy

Yes

Print Name:

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 other, please specify:

Which service/s do they use? (if appliable)

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.

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:

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

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

Equal Opportunities and Monitoring

Please state the type of disability your child has:

Specific learning difficulty

Moderate learning difficulty

Severe learning difficulty

Profound & multiple learning difficulty

Social, emotional and mental health

Hearing impairment

Visual impairment

Multi-sensory impairment

Physical disability

Autistic spectrum disorder

Other difficulty / disability

SEN support but no specialist assessment of type of need

Please state your child’s ethnicity:

White British

White Irish

Traveller of Irish Heritage

Any other White background

Gypsy/Roma

White and Black Caribbean

White and Black African

White and Asian

Any other Mixed background

Indian

Pakistani

Bangladeshi

Any other Asian background

Caribbean

African

Any other Black background

Chinese

Any other ethnic group

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

One Page Profile

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

Name:

I like:

I don't like:

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.

How I like to be supported:

My goal at Youth Club is: