Stay and Play registration form
In order to book Stay and Play sessions at ELHAP, please complete the registration form below.
CHILD'S NAME - AND PARENT/CARER'S DETAILS
Forename
Surname
Date of birth
Day
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
13th
14th
15th
16th
17th
18th
19th
20th
21st
22nd
23rd
24th
25th
26th
27th
28th
29th
30th
31st
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
Main Carer's Title
Main Carer's First Name
Main Carer's Surname
Relationship to Child or Young Person
Please Select
Aunt
Brother
Carer
Dad
Father
Foster Carer
Friend
Godmother
Grandma
Grandmother
Grandparent
Guardian
Husband
Liliya Slavcheva
Manager of Home (Supported Living)
Mother
Mother & Father
Mother and Apointee
Mum
Nan
Nana
Other
Parent
Partner
Relation
Sister
Son/Carer
Special Guardian
Step-Father
Step-mother
Home phone number
Mobile number
CHILD'S NAME - AND PARENT/CARER'S DETAILS
Email address
ADDRESS
First line of Address
Second line of address
Town
County
Post Code
PLEASE PROVIDE DETAILS OF SOMEONE WE CAN CONTACT IN AN EMERGENCY
We require each child to have at least one emergency contact (other than the main carer). This is in case of emergency when the main carer cannot be contacted.
Emergency Contact Name
Relationship to Child or Young Person
Phone number
TELL US ABOUT YOUR CHILD, THEIR NEEDS AND WHAT THEY LIKE TO DO
Disability
Autistic Spectrum Disorder or Asperger Syndrome
Blind or partially sighted
Complex disabilities
Deaf or hearing impairment
Emotional/behavioural difficulties
Mental health difficulties
Multiple disabilities
Temporary disability after illness or accident
Unseen disability (e.g. diabetes, epilepsy, heart condition)
Wheelchair user or mobility difficulties
Prefer not to say
Unknown
Please give further details about disability
What does your child enjoy doing?
DOES YOUR CHILD HAVE ANY HEALTH CONDITIONS?
Diabetes
Please Select
No
Yes
Haemophilia
Please Select
No
Yes
Asthma
Please Select
No
Yes
Allergies
Please Select
No
Yes
Anaphylaxis
Please Select
No
Yes
Epilepsy
Please Select
No
Yes
Please give further details of medical or health needs
WOULD YOUR CHILD ATTEMPT TO:
Would your child try to do any of the following?
ELHAP is very secure - but it is useful to know if your child might try really hard to climb over fences, run through open gates etc
Please Select
No
Yes
possibly
WOULD YOUR CHILD ATTEMPT TO:
Climb over fences or gates?
Please Select
No
Not answered
Yes
CHALLENGING BEHAVIOUR
Does your child ever exhibit challenging or difficult behaviours
Please Select
No
Sometimes
Yes
Please provide more details. Are there any triggers, stressful situations, ways of responding that might upset your child etc
TELL US ABOUT YOUR OTHER CHILDREN COMING TO STAY AND PLAY
Is there anything else you'd like us to know?
Please provide names and ages of siblings who might come to Stay and Play
PHOTOS AND VIDEOS CONSENT
Images of my child used in ELHAP publicity, reports, videos
Please Select
Yes
No
Images of my child used by third parties - newspapers, funders
Please Select
Yes
No
WILL YOUR CHILD REQUIRE MEDICATION WHILST AT ELHAP?
We have strict rules about the storage and administration of all medication - it is really ok to give medication at ELHAP but we just need to know what it is and how it will be stored (sometimes we might need you to store the medication in our secure medication cupboard or our secure portable medication bags)
MONITORING
Gender
Please Select
Male
Female
Transsexual Female
Transsexual Male
Non-binary
Prefer not to say
Unknown
Ethnicity
Please Select
Asian/Asian British - Bangladeshi
Asian/Asian British - Chinese
Asian/Asian British - Indian
Asian/Asian British - Pakistani
Asian/Asian British - Other
Asian/Asian British - Unspecified
Black/African/Caribbean/Black British - African
Black/African/Caribbean/Black British - Caribbean
Black/African/Caribbean/Black British - Other
Black/African/Caribbean/Black British - Unspecified
Mixed/multiple ethnic groups - White and Asian
Mixed/multiple ethnic groups - White and Black African
Mixed/multiple ethnic groups - White and Black Caribbean
Mixed/multiple ethnic groups - Other
Mixed/multiple ethnic groups - Unspecified
White - Welsh/English/Scottish/Northern Irish/British
White - Irish
White - Eastern European
White - Gypsy, Roma or Irish Traveller
White - Other
White - Unspecified
Other ethnic group - Arab
Other ethnic group - Other
Prefer not to say
Unknown
Mixed/multiple ethnic groups - White and Black/African/Caribbean/Black British - African
Mixed/multiple ethnic groups - White and Black/African/Caribbean/Black British - Caribbean
Is your child registered disabled?
Please Select
Yes
No
Prefer not to say
Unknown
Disability - please specify
Autistic Spectrum Disorder or Asperger Syndrome
Blind or partially sighted
Complex disabilities
Deaf or hearing impairment
Emotional/behavioural difficulties
Mental health difficulties
Multiple disabilities
Temporary disability after illness or accident
Unseen disability (e.g. diabetes, epilepsy, heart condition)
Wheelchair user or mobility difficulties
Prefer not to say
Unknown
Religion
Please Select
Baha'i
Buddhist
Christian
Hindu
Jain
Jewish
Muslim
No religion, affiliation or belief
Pagan
Sikh
Zoroastrian
Prefer not to say
Unknown
Does your child have an EHCP?
Please Select
No
Unsure
Yes
Submit
Please confirm the following details are correct
×
CHILD'S NAME - AND PARENT/CARER'S DETAILS
Forename
Surname
DateOfBirth
Email address