Youth Group Registration Form
Dear parent/carer,

Please fill in this form to provide us with some more details about your child - it will give us some background and a starting point to discuss a potential place at a youth group for your child. If anybody has any issues filling in this online form, please call the office on 01189 594 594 and ask for Sarah Brown - we can provide a paper copy if needed.

Please note that we do not hire 1:1 support for any child who wants to attend our youth groups - all children need to be able to manage well in a 1:4 staff:child setting.

If you would like to make a donation to Autism Berkshire, we would really appreciate your support. The link to donate can be found here: http://www.autismberkshire.org.uk/donate/.

Thank you and Best wishes,

The Autism Berkshire Team
Email address *
Have you attended an Autism Berkshire youth group before?
Which youth group would your child like to attend? *
Required
If my child is offered a place, I agree that they will attend all sessions, and that if my child does not attend regularly, their place may be given to another child on the waiting list. Each case will be considered on an individual basis if, for example, your child is ill. *
Required
Have you/do you access any other activities that Autism Berkshire offers?
Parent/carer (main contact) first name: *
Your answer
Parent/carer last name: *
Your answer
Address: *
Your answer
Postcode: *
Your answer
Parent/carer email address: *
Your answer
Parent/carer telephone number: *
Your answer
Tick the box that best describes you *
Required
Child's first name: *
Your answer
Child's last name: *
Your answer
What is your child's age? *
What is your child's date of birth? *
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What is your child's gender? *
Which school does your child attend? *
Your answer
Can your child manage well in a 1:4, staff:child situation? *
If no, please provide some more details about the support your child needs
Your answer
Does your child have an Autism diagnosis? *
Please provide a date of diagnosis if your child has been diagnosed.
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Does your child have any additional health needs? Please provide some details.
Your answer
I am happy for my child to receive first aid or emergency medical treatment by trained Autism Berkshire staff or medical authorities. *
Please list any activities your child enjoys/attends. *
Your answer
What are your child's interests? *
Your answer
Please describe any difficulties your child has with communication. *
Your answer
Does your child often become physically or verbally aggressive? *
If yes, please provide details.
Your answer
Does your child abscond from settings or people (e.g. school, home or groups)? *
If yes, please provide details.
Your answer
How did you hear about Autism Berkshire? *
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