Paper Bits - Seven Up Charity

Seven-Up Registration Form

NAME OF YOUNG PERSON (IN FULL) *
AGE *
SCHOOL *
GENDER
MALEFEMALE
ETHNICITY
NHS NUMBER *
GP NAME *
GP ADDRESS *
GP TELEPHONE *

The following questions help ensure that we have the right staff and resources to support your children Seven Up WILL NEVER exclude a child on the grounds of their disability.

What disabilities or additional needs does your child have?
Individual needs that staff must know e.g. allergies/ medication/ disability support: – (It is important that we know if your child needs medication or has intimate care needs so that we can ensure that we have staff on site to meet their needs)

Parent/Carer Details

NAME OF PARENT/CARER *
FULL POSTAL ADDRESS *
POSTCODE *
HOME PHONE
MOBILE NUMBER
HOME NUMBER
EMAIL ADDRESS *
EMAIL ACCESSIBLE VIA PHONE
YESNO

COLLECTION: Please give the name of the person/s over the age of 16 who will be collecting your children. Please ensure that the named person for collection brings ID, as this may be requested.

It will be your responsibility to alert the Seven Up team via a call or text of any changes to the collection to enable them to reassure your child.

(1) NAME
(1) RELATIONSHIP
(2) NAME
(2) RELATIONSHIP
(3) NAME
(3) RELATIONSHIP

EMERGENCY CONTACT: It is essential that you provide the names of two adults and/or an organisation (CERS etc.) that can be contacted in an emergency if you cannot collect your child within 15 minutes from the end of a session.

(1) NAME *
(1) RELATIONSHIP *
(1) HOME NUMBER
(1) MOBILE NUMBER *
(2) NAME *
(2) RELATIONSHIP *
(2) HOME NUMBER
(2) MOBILE NUMBER *

OTHER AGENCIES:

Please give name & contact details of any other agencies currently working to support your family e.g. Doctor, Family Support Worker, Social Worker, fCAF etc
CONSENT I agree that:-
Staff may give any first aid/medical treatment which is urgently required.
Staff may use antiseptic wipes &/or plasters if necessary (unless otherwise indicated in the allergy information)
Staff may administer sun cream if necessary Staff may take photographs of my child (photos are only used as a record of sessions)
Young person may go on short outings away from the delivery site to access local amenities e.g. park, shops etc. If you’d like to keep getting the occasional email from us; you need to tell us. To stay opted in and to continue receiving our updates.
PRINT NAME *
DATE *

Please enter any two digits in the box below. *Example: 12

Verification

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