Spring Harvest - Additional Needs Information

Young Person

Please tell us about the child/young person with additional needs.

First Name:*

Your child's first name only

Family Name:* Any other name that they are known by:

Photo:

Please attach a recent photograph of your child. This is not essential, but would be helpful. Max photo size 5MB (must be .jpg or .png)

Gender:* Male Female

Date of birth:

yyyy

Age on 31st March 2012
will be

Young people in the 11-14s and 15+ programmes are free to come and go from these programmes as they wish. Please check on programme times as youth programme breaks may differ from those of the adult programme.

Siblings My child has siblings in the child or youth programme:

Names and ages:

Previous Attendance My child has attended Spring Harvest before:

When or other details:

Level of Support Needed Under normal circumstances, how does your child function in a small group:

Needs no support

Needs some support

Needs a high level of support

Does your child receive support
at school or church:

Yes No

Level of support school or church offers:

Carers My child needs one-to-one care:

Please note that we are unable to provide one-to-one care so if your child needs that level of support a family member or trusted friend may accompany them in the programme

Please name each carer who will support your child at Spring Harvest.

Carer 1: Carer 2: Carer 3: Carer 4:

Please email clearly labelled photos of all carers to specialneeds@springharvest.org. Or post them to Joy Townhill at the Spring Harvest office. All carers must read and agree to follow the Carers Guidelines.

Physical Issues

Please indicate which, if any, of the following apply to your child. You may tick as many as are applicable.

My child uses a wheelchair

My child has difficulties with balance and may find stairs difficult

My child will or may need help with toileting and I give permission for an approved member of the Spring Harvest team to assist them in this way (please tell us more about the help which may be needed in the space below)

My child will or may need help with toileting and I do not give permission for Spring Harvest team members to give such assistance and will accompany my child in their programme

My child may need reminding to go to the toilet

Please give further information about your child's physical needs which we should be aware of.

Behvioural Issues

Please indicate which, if any, of the following apply to your child. You may tick as many as are applicable

Behavioural issues will not usually exclude a child from the programme, but it is essential we are aware of them.

My child is very shy with new people, especially in groups

My child is likely to wander if not engaged in the programme

My child may become aggressive in unfamiliar situations

My child would appreciate a cuddle if upset

Do not cuddle if upset, it may frighten my child further

My child has been diagnosed with ADHD

The following activities or situations may upset or frighten my child:

Please give further information about your child's behaviour which we should be aware of, including the best way to comfort or reassure them.

Medical Conditions

Spring Harvest Team are not medically trained and cannot be responsible for ensuring medication is taken at specific times. In a medical emergency, they will ask Butlins to provide medical assistance and try to contact you immediately.

Designated team members have received basic instruction in the storage and administration of epi-pens. Children who can, and do, administer their own medication, such as an inhaler, may do so as required within the programme.

Athsma Inhalers

My child carries an asthma inhaler.

Who will have the inhaler during the programme?

In normal settings and I am happy for my child to have it with them in the programme and administer it when appropriate

They will need assistance to administer it. I give permission for a designated team member to offer such assistance

Epi-pens

My child carries an epi-pen.

My child is allergic to the following and may need their epi-pen if they contact it:

Who will have the Epi-pen during the programme?

My child will hold the epi-pen during the programme

I would like the epi-pen held by a designated team member during the programme

It is the responsibility of the parent/guardian to bring the epi-pen and give it to and collect it from the identified team member at the beginning of each session. Epi-pens must NOT be left with team members outside programme hours.

What should we do in a medical emergency?

I give permission for the epi-pen to be administered by a nominated and trained team member if it is reasonably considered that any delay in administering the epi-pen would create a significant risk to the health of my child.

Please do not administer my child's epi-pen but do the following:

Other Medical Conditions

Please give details of any medical conditions that we should be aware of and the dosage and possible side effects of any medication your child is receiving. Please include information about their awareness of their condition.

Name and Telephone Number of GP

If your child has a medical condition which may require attention at Spring Harvest, please give GP details.

Other Information

If your child needs support for any other reason, please give a brief description of their situation. Please also use this space for anything else you would like us to be aware of, including any subjects or topics that may upset them.

Questions? Concerns?

Additional Needs Information