Family Voice Membership Form
The following details will be entered onto our database, and you will be signed up to our monthly newsletter detailing the work that we are currently undertaking, with information about any upcoming events you may find useful. Your details will not be shared with any other organisation and will be stored in accordance with GDPR legislation. You can withdraw your details from the database at any time by sending a request to our registered address, or unsubscribe from our newsletter using the link on the bottom of the email.
This information helps us to tailor our services to meet the needs of our beneficiaries and target out work where needed. Some information such as numbers of areas of needs specified help us with monitoring where we receive grants for specific work.
* Required
The Date on Membership Form
MM
/
DD
/
YYYY
Full Name
Your answer
Post Code
Your answer
Telephone Number
Your answer
Email Address
Your answer
Age
Choose
18-25
26-35
36-45
46-55
56-65
66-75
76-85
86-95
Marital Status (Optional)
Married
Divorced
Widowed
Single
Co-habiting
Clear selection
Gender
Female
Male
Other:
Clear selection
Ethnicity
White British
White European
Mixed Race
Asian
Asian British
Black
Black British
Other:
Clear selection
Economic Status (optional)
Paid Work
Self Employed
Voluntary Sector
In Education/Training
Not in Work
Other:
Clear selection
Where you live (optional)
Home Owner
Private Tenant
Social Housing Tenant
Other:
Clear selection
Gender of CYP 1 with SEND
Choose
Male
Female
Other
Age of CYP 1
Choose
0-5
6-10
11-15
16-19
20-25
25+
CYP 1 Area of Need
ASD
ADHD
SpLD
MLD
SLD
PMLD
Downs Syndrome
Cerebral Palsy
Hydrocephalus
Genetic Disorder
On the Pathway
Anxiety
Personality Disorder
Schizophrenia
Depression
Eating Disorder
Asthma
Epilepsy
Traumatic Brain Injury
LD
Other:
What Educational Setting does CYP 1 attend
Choose
Mainstream Primary
Mainstream Secondary
Mainstream Private
Specialist - Maintained in County
Specialist - Private
Specialist - Out of County
Specialist - Hub Placement
Post-16
Electively Home Educated
Out of Education
Pre-school/nursery
PRU
Mainstream
Specialist
Gender of CYP 2 with SEND
Choose
Male
Female
Other
Age of CYP 2
Choose
0-5
6-10
11-15
16-19
20-25
25+
CYP 2 Area of Need
ASD
ADHD
SpLD
MLD
SLD
PMLD
Downs Syndrome
Cerebral Palsy
Hydrocephalus
Genetic Disorder
On the Pathway
Anxiety
Personality Disorder
Schizophrenia
Depression
Eating Disorder
Asthma
Epilepsy
Traumatic Brain Injury
LD
Other:
What Educational Setting does CYP 2 attend
Choose
Mainstream Primary
Mainstream Secondary
Mainstream Private
Specialist - Maintained in County
Specialist - Private
Specialist - Out of County
Specialist - Hub Placement
Post-16
Electively Home Educated
Out of Education
Gender of CYP 3 with SEND
Choose
Male
Female
Other
Age of CYP 3
Choose
0-5
6-10
11-15
16-19
20-25
25+
CYP 3 Area of Need
ASD
ADHD
SpLD
MLD
SLD
PMLD
Downs Syndrome
Cerebral Palsy
Hydrocephalus
Genetic Disorder
On the Pathway
Anxiety
Personality Disorder
Schizophrenia
Depression
Eating Disorder
Asthma
Epilepsy
Traumatic Brain Injury
LD
Other:
What Educational Setting does CYP 3 attend
Choose
Mainstream Primary
Mainstream Secondary
Mainstream Private
Specialist - Maintained in County
Specialist - Private
Specialist - Out of County
Specialist - Hub Placement
Post-16
Electively Home Educated
Out of Education
Gender of CYP 4 with SEND
Choose
Male
Female
Other
Age of CYP 4
Choose
0-5
6-10
11-15
16-19
20-25
25+
CYP 4 Area of Need
ASD
ADHD
SpLD
MLD
SLD
PMLD
Downs Syndrome
Cerebral Palsy
Hydrocephalus
Genetic Disorder
On the Pathway
Anxiety
Personality Disorder
Schizophrenia
Depression
Eating Disorder
Asthma
Epilepsy
Traumatic Brain Injury
LD
Other:
What Educational Setting does CYP 4 attend
Choose
Mainstream Primary
Mainstream Secondary
Mainstream Private
Specialist - Maintained in County
Specialist - Private
Specialist - Out of County
Specialist - Hub Placement
Post-16
Electively Home Educated
Out of Education
Number of siblings without needs
Choose
1
2
3
4
5
6
7
8
9
10
Which particular areas of special or additional needs are you interested in? (optional)
Early Years
Physiotherapy
Occupational Therapy
Speech and Language
Health (general)
Education
Preparing for Adulthood
Social care
Other:
Are you a member of any other relevant organisations? (please list) (optional)
Your answer
Have you had any difficulties with any particular service/area of special or additional needs? Please give details (optional)
Your answer
What Time of Day is Best for you to Attend Meetings/Focus Groups/ Workshops (optional)
Morning
Afternoon
Evening
Are you Interested in Becoming a Parent Representative?
*
Yes
No
Would you like to be Involved with Family Voice or kept Informed?
Informed
Involved
Clear selection
Declaration - Please note that by ticking "yes" you are confirming you consent to your details being held in our database, and being kept informed via the details you have provided on the work being conducted by Family Voice, and any upcoming events that you may be interested in. You may withdraw this consent at any time by submitting a request via post to our registered address.
*
YES
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