Parent & Club Booking Form Parent & Club Booking Form Our Children & Young People’s Clubs for children & young people with complex needs, learning disabilities and autism are commissioned by Carmarthenshire County Council’s Children’s Disability Team and part-funded through Carers Trust Crossroads Sir Gâr charitable funds. They aim to provide children with supported and fun play opportunities whilst also providing their carers, including siblings, with time for themselves. Step 1 of 6 - You & Your Child 0% Child's InformationChild's Full Name*Child's Gender*MaleFemaleDate of Birth* Date Format: DD slash MM slash YYYY Name of SchoolSchool ClassAddress*This is MePlease upload a photograph of your childParent & Carer InformationParent/Carer Name*Parent/Carer Address (if different)Home Telephone NumberWork Telephone NumberMobile Telephone NumberEmail Address 📧 GP Surgery InformationGP Surgery Name*GP Surgery Address*GP Phone Number*Is your child on prescribed medication?*YesNo BookingWe have after-school clubs in Canolfan Elfed, Carmarthen every Tuesday, in the Myrddin Unit, Carmarthen every Wednesday and in Heol Goffa, Llanelli every Thursday. We also have Saturday clubs in Johnstown and Caemaen every Saturday. I would like my child to attend the club on the following days:I would like my child to attend these clubs* After School Club, Heol Goffa, Llanelli (5-19 years) After School Club, Canolfan Elfed, Carmarthen (12-19 years) After School Club, Myrddin Unit, Carmarthen (5-11 years) Saturday Club, Johnstown Centre, Carmarthen (12-19 years) Saturday Club, Caemaen Centre, Llanelli (12-19 years) Heol Goffa, Llanelli (5-19 years)* Thursday 16th January Thursday 23rd January Thursday 30th January Thursday 6th February Thursday 13th February Thursday 5th March Thursday 12th March Thursday 19th March Thursday 26th March Canolfan Elfed, Carmarthen (12-19 years)* Tuesday 14th January Tuesday 21st January Tuesday 28th January Tuesday 4th february Tuesday 11th February Tuesday 3rd March Tuesday 10th March Tuesday 17th March Tuesday 24th March Myrddin Unit, Carmarthen (5-11 years)* Wednesday 15th January Wednesday 22nd January Wednesday 29th January Wednesday 5th February Wednesday 12th February Wednesday 4th march Wednesday 11th March Wednesday 18th march Wednesday 25th March Saturday Club, Johnstown Centre, Carmarthen (12-19 years)* Saturday 11th January Saturday 18th January Saturday 25th January Saturday 1st February Saturday 8th February Saturday 15th February Saturday 29th February Saturday 7th March Saturday 14th March Saturday 21st March Saturday 28th March Saturday Club, Caemaen Centre, Llanelli (12-19 years)* Saturday 11th January Saturday 18th January Saturday 25th January Saturday 1st February Saturday 8th February Saturday 15th February Saturday 29th February Saturday 7th March Saturday 14th March Saturday 21st March Saturday 28th March About MeHow I like to communicate... (spoken word, sign & symbols)What I need help with... (food, drink, personal care)How I am able to get about... (mobility)My favourite things are... (music, sensory play, games...)What makes me happyWhat makes me sadPlease use this space if you would like to tell us anything else you would like us to know... Emergency Contact DetailsIn case of emergencies please provide alternative names to contact, including their relationship to your child. These are other named persons authorised to collect your child or who can be contacted in an emergency. Please note that we will need a photograph of each person authorised to collect a child due to requirements stipulated by Care Inspectorate Wales. First Emergency Contact's Name*First Emergency Contact's Relationship to Child*First Emergency Contact's PhotographIf you don't provide a photograph, one will need to be taken later. This is to comply with requirements stipulated by Care Inspectorate Wales.First Emergency Contact's Address*First Emergency Contact's Home Phone NumberFirst Emergency Contact's Work Phone NumberFirst Emergency Contact's Mobile Phone NumberFirst Emergency Contact's Email Address Second Emergency Contact's Name*Second Emergency Contact's Relationship to Child*Second Emergency Contact's PhotographIf you don't provide a photograph, one will need to be taken later. This is to comply with requirements stipulated by Care Inspectorate Wales.Second Emergency Contact's Address (if different to first)Second Emergency Contact's Home Phone NumberSecond Emergency Contact's Work Phone NumberSecond Emergency Contact's Mobile Phone NumberSecond Emergency Contact's Email Address ConsentPlease read the statements below. Please tick "yes" if you consent to each statement, otherwise, please tick "no".I give permission for my child to be photographed for promotional materials (including our website or brouchures)*YesNoI give permission for my child to be photographed for promotional materials in the local press*YesNoI give permission for my child to have sun-screen applied if needed (to be provided by yourselves)*YesNo Health Needs and MedicationWhat are your child's health needs (including diagnosis, if relevant)*Does your child have a known allergy?*YesNoPlease provide any allergy detailsPrescribed Medication Please provide details of any medication your child has been prescribed. Will medication need to be administered during the club hours?*YesNoPlease specify medication that will need to be administered during club hoursMedicationDosageTime to be Administered A separate medication form will need to be completed once booking is confirmedI give consent for medication, as prescribed by my child's GP to be administered to my child*YesNo
