spectrum socials interest form

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Please answer these questions to help me match children with similar ages, abilities, and interests.

Name of parent/ carer's first name: *

Name of parent/ carer's last name:

Name of child:

Name of second parent/ carer (full name):

Please leave your email for correspondence *

Please give your child's date of birth *

YYYY

What is your child's gender?

Male

Female

Prefer not to say/ Other

Clear selection

What is your postcode?

Are you willing to travel to ... ?

Central London

North London

South London

West London

East London

Other:

How would you describe your child's communication level?

Conversational

Simple speech - single words and short phrases

Non-vocal and uses communication other than speech (eg PECS or sign)

Non-verbal

Clear selection

What diagnoses does your child have?

Autsim

ADHD

Learning disabilities

Anxiety or depression

Language disorder

No diagnosis yet waiting

Other:

Does your child exhibit any high risk challenging behaviour?

Yes, frequently

Sometimes

Never/ rarely

Clear selection

If you marked yes or sometimes to the previous question, please briefly state common triggers and behaviours.

What are your child's preferred interests?

Buses

Trains

Playing with toys

Computer games

Football

Trampolining

Drawing

Arts and crafts

TV and films

Physical play

Sensory play

Other:

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Is there anything specific we should know to better support and accommodate you and your child?

Phone number (only to be used at events):

Sometime at events we take photos that we may occasionally share on social media, grant applications or as promotional content. Please let us know your preference out of the options below:

I am happy to give permission for my child’s photo or video to be used on Spectrum Socials’ social media, grant applications, website and any promotional materials.

I give permission for my child’s photo or video to be used with blurred out face only.

I do not want my child’s photo or video to be used by Spectrum Socials.

I would rather there were no photos taken of my child at all.

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Does your child have any dietary requirements or allergies? Please detail:

In a sentence or two, how would you describe your child, their level, and what you and they are looking for from Spectrum Socials?

Please confirm you consent to Spectrum Socials CIC storing and using the information provided for the purpose of organising and delivering services, in line with the Spectrum Socials CIC Privacy Policy. (https://spectrumsocials.co.uk/privacy-policy)

I consent and I understand I can withdraw my consent at any time.

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