Application Form

Comments

Transcription

Application Form
A Voluntary Organisation for
Young People with Special Needs
APPLICATION FORM - CAMP CANDO
Camp Cando is free of charge. However, if you feel you would like to make a donation, please visit
our fundraising page at www.virginmoneygiving.com or forward your donation with the application
form.
*********************************************************************************************************************************
It is very important that you give as much detailed information as possible to enable us
to assess your application for a holiday this year and also to enable us to meet your
child’s needs during their stay. Thank you.
*********************************************************************************************************************************
Contact Details
Child’s Name:
Child’s Date of Birth:
Child’s Age:
Parents/Carers Name:
Home address:
e-mail address:
Telephone Number:
Mobile Number:
Collection Point
Which location would you like to drop/collect your child to/from (please tick as appropriate):
Michael Tippet School:
Turney School:
Yes
Yes
MEDICAL CONSENT FORM
I hereby give consent for my child/ward to attend Camp Cando.
I also give consent for my child/ward to receive any medical treatment deemed necessary by a
qualified medical practitioner whilst on Camp Cando and have detailed on the attached Medical
Questionnaire any necessary information.
Name of Child:
Signature of Parent/Carer:
Please print name:
Registered address: 19 Ian Road, Billericay, Essex, CM12 0JZ
Registered Charity No. 800323
www.campcando.org
Date:
Page | 1
A Voluntary Organisation for
Young People with Special Needs
GENERAL
Are you happy for Camp Cando to use photographs taken of your child/ward
whilst at Camp on their website?
Yes
No
Are you happy for Camp Cando to provide photographs to our approved sponsors
for use within their media?
Yes
No
Please give details of bedtime routines and morning routines, (eg. Glass of milk before bed, etc)
Does your child/ward have difficulty sleeping all night?
Yes
No
If yes, please give further details (eg. approximate time of waking, time taken to fall asleep)
Has your child/ward ever slept in a top bunk?
Yes
No
Please give details of child’s brothers or sisters, (ie. names and ages)
Please state any special likes and dislikes (excluding food) and any other information you
think will help make for an enjoyable holiday! (continue on a separate page if you need to)
Registered address: 19 Ian Road, Billericay, Essex, CM12 0JZ
Registered Charity No. 800323
www.campcando.org
Page | 2
A Voluntary Organisation for
Young People with Special Needs
MEDICAL QUESTIONNAIRE
Child’s Name:
HEALTH & WELL-BEING:
Nature of child’s disability:
Any other medical conditions (ie.
asthma, epilepsy, eczema)
Doctor’s Name:
Doctor’s Address:
Doctor’s Tel No:
Yes
No
Yes
No
Is your child/ward allergic to anything (eg. foods, medication, insect bites, etc)?
If yes, please give details below and supply medication (if applicable):
Yes
No
Does your child/ward suffer from travel sickness? If yes, please supply
medication (if applicable)
Yes
No
Does your child/ward display any behavioural problems at home?
If yes, how is it dealt with?
Yes
No
Does your child/ward have communication problems?
If yes, please give details:
Does your child/ward use sign language or Makaton?
Registered address: 19 Ian Road, Billericay, Essex, CM12 0JZ
Registered Charity No. 800323
www.campcando.org
Page | 3
A Voluntary Organisation for
Young People with Special Needs
MEDICAL QUESTIONNAIRE CONTINUED
Child’s Name:
HEALTH & WELL-BEING CONTINUED:
When was your child/ward last vaccinated against
tetanus?
Date:
Does your child/ward have any fears/phobias?
If yes, please give details:
Yes
No
Yes
No
MEDICATION
Does your child/ward require any medication?
If yes, please give the following details for each type of medication:
Name of Medication:
Dosage:
Frequency of
Dosage:
How do you get your
child/ward to take the
medication (ie, crushed in
water/food, whole with drink,
etc):
Are you happy for Inbuprofen syrup to be administered if needed (ie. for headache,
period pain, etc):
Yes
No
Yes
No
Does your child suffer from incontinence? (if yes, please supply pads etc)
Daytime
Yes
No
Night-time
Registered address: 19 Ian Road, Billericay, Essex, CM12 0JZ
Registered Charity No. 800323
www.campcando.org
Yes
No
Both:
Page | 4
A Voluntary Organisation for
Young People with Special Needs
DIETARY REQUIREMENTS
Child’s Name:
DIETARY REQUIREMENTS:
Does your child/ward have any special dietary needs?
If yes, please give details:
Yes
No
Does your child/ward have any food allergies?
If yes, please give details:
Yes
No
Please give details of any foods/drinks your child/ward particularly likes:
Please give details of any foods/drinks your child/ward particularly dislikes:
Please provide any specific meal time routines (if appropriate):
********************************************************************************************************************************
PLEASE RETURN COMPLETED APPLICATION FORM AS SOON AS POSSIBLE IN THE
ENVELOPE PROVIDED OR E-MAIL TO [email protected]
If you have any queries please do not hesitate to contact:
Steve Smith - 07900 514147 or Julie Matthews - 07779 577326; or e-mail – [email protected]
********************************************************************************************************************************
Registered address: 19 Ian Road, Billericay, Essex, CM12 0JZ
Registered Charity No. 800323
www.campcando.org
Page | 5

Similar documents