Summer 2016 SEN Camp Registration Form
Key event information

Venue: Albemarle School, Princes Way, Southfields, SW19 6JP

Dates:
Mon July 25th – Fri July 29th inclusive (9.30am – 3.30pm daily)
Tues August 30th – Fri September 2nd inclusive (9.30am – 3.30pm daily)

Price:  If you book & pay before 1st July 2016 the price is £60/day, discounted to £50/day if all course days are booked. If you book & pay after 1st July 2016, the price is £60/day + VAT, discounted to £50/day + VAT if all course days are booked. Unfortunately we don't accept childcare vouchers. Please enquire regarding local authority funding support as this is very much a possibility.

Activities:  Camp will involve a series of choices between dynamic and calming activities as per previous camps.  These will include quick cricket, sleeping lions, board games, rounders, jigsaw making plus some brand new Summer activities.

Capacity:  Limited to 25 children per day.

Role Models:  Will be a minimum of 1:5 staff to children ratio.  All Role Models have been DBS checked, reference checked and have extensive special needs childcare experience.  It will include teachers from Blossom House, the special needs school in Motspur Park.

Further information and a short video can be found on our website:
http://www.rolemodels.me/sen-summer-camps-2016/ 

Any questions, please call Hugo Shephard on 07825 598344 or email at Hugo@rolemodels.me

This application forms part of the process for being able to understand the needs of the children.


Sign in to Google to save your progress. Learn more
Part One - General
Please select the dates your child will be attending: *
Required
Parent/Guardian Name: *
Email Address: *
Contact Number: *
Emergency contact name (must be different to the name given above): *
Emergency contact number: *
Child's name: *
Child's DOB: *
MM
/
DD
/
YYYY
Child's school: *
Billing address: *
Occasionally, we may take photographs of children during Role Models activity camps. To comply with the Data Protection Act 1988, we need your permission before we can photograph your child.  In respect to this, the following shall apply: • If we use photographs of individual children, we will not use the name of your child in the accompanying text or photo caption.   • We will only use images of children who are suitably dressed.  Please confirm you are happy for us to use these images in our marketing materials or in other printed publications that we produce, as well as on our website? *
Your answer to this question supersedes the marketing section within the T&Cs.
Required
Please confirm you are happy for us to use any testimonials you send us via email in our marketing materials or in other printed publications that we produce, as well as on our website?   *
Please confirm you accept the Terms and Conditions of the Role Models SEN Camp *
To view Terms and Conditions please visit: http://www.rolemodels.me/role-models-sen-camp-tcs/ ‎
Part Two - Special Needs
What is your child's diagnosis? *
In the absence of a confirmed diagnosis, please advise of your child's difficulties: *
Is your child statemented? *
Does your child have 1:1 support at school? If so, how many hours per week and when is this essential? *
Does your child require 1:1 support at all times? *
Can your child attend a group activity without 1:1 support? *
Do you believe your child has mild to moderate special needs?   *
Does your child have learning difficulties? *
Does your child have physical difficulties? *
Does your child have behavioural difficulties? *
If your child has behavioural difficulties, please provide an example of their behaviour with the cause, effect and strategy used to calm them down:
For example: “other children were laughing and Jenny found it too loud and hid under the classroom table. Jenny was massaged with a sensory toy to reduce anxiety”.
Is your child ever physically aggressive towards other children? If so, please provide an example: *
Has your child ever needed to be physically restrained? If so, please provide details i.e. the estimated date, the trigger, behaviour and outcome. *
Have any specific occupational therapy or speech & language therapy strategies been put in place for your child? *
For example, a sequence of exercises to help them to regulate their energy levels, a fidget toy to help with their attention, language modeling, using a maximum number of words or gaps to support processing time, using their name to gain attention etc.
Please describe your child’s perfect day: *
Please describe your child’s worst possible day: *
Does your child have a tendency to run off? *
Part Three - Further Information
Does your child have any allergies, intolerances or medical requirements that we need to be aware of? *
Does your child need encouragement and/or supervision going to the toilet? *
Is your child likely to have trouble separating from their parents / carers in the morning? *
How did you hear about us? *
Please add any further information below which you deem relevant and which has not been captured above:
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms