Secondary Years Family Day
Saturday 12th November 2016 - Thornhill Church Centre, Excalibur Drive, Cardiff, CF14 9GA
First Name *
Your answer
Surname *
Your answer
Relationship to the Child *
Address 1 *
Your answer
Address 2
Your answer
Town *
Your answer
County *
Your answer
Postcode *
Your answer
Telephone number (preferably mobile) *
Your answer
Email (we email whenever possible to save on postage and trees)
Your answer
Please confirm your email address
Your answer
Are you a member of HemiHelp? *
Other Adults Attending
Adult 2 First Name
Your answer
Adult 2 Surname
Your answer
Adult 2 Relationship to Child
Adult 3 First Name
Your answer
Adult 3 Surname
Your answer
Adult 3 Relationship to the Child
Adult 4 First Name
Your answer
Adult 4 Surname
Your answer
Adult 4 Relationship to the Child
About You
To help us monitor the effectiveness of our events, please answer the following questions. This information is used when applying to Trusts for essential funding of HemiHelp services.
Is this the first HemiHelp event you have attended? *
Knowledge
Before attending the event, how much do you know about the physical and learning barriers that can arise for children with hemiplegia during Secondary School? *
Before attending the event, how much do you know about the issues your child with hemiplegia might face as they move on to become a more independent teenager? *
Confidence
Before attending the event, how confident are you in working with the teachers to support your child through Secondary School?
What do you want to get out of attending this event?
Please rank from 1-5 how important the following are to you (1-5 where 1 is the LEAST important and 5 is the MOST important)
*
1
2
3
4
5
To gain knowledge about how you can help your child's teachers understand their hemiplegia
To gaiin knowledge about the benefits of physiotherapy for teenagers
To find out more about supporting your child to become a more independent teenager?
To meet other families?
Media Consent
PHOTOGRAPHS HemiHelp may take photographs of you and your child participating in activities and use these in internally produced publications (e.g. our magazine, Annual Review, Posters) and/or on our website and social media channels (e.g. Facebook, Twitter, Flickr). As part of our aim to raise awareness of hemiplegia, they may also appear in other targeted print media (e.g. medical/educational publications, local and national newspapers) and approved online channels (e.g. websites/social media).
VIDEO HemiHelp also takes video footage at events to be used in our internally produced videos. These may appear on our website and social media channels (e.g. Facebook, Twitter, our YouTube channel). Please check the relevant box to state your preference on these issues.
Health and Safety
Please detail below, any relevant medical conditions (apart from hemiplegia) and any medication your child(ren) may currently be taking (e.g. for epilepsy, asthma etc). If there is more than one child on this form, please state the name of the child you are referring to.
Your answer
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