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 3rd October Thursday 10th October Thursday 17th October Thursday 24th October Thursday 7th November Thursday 14th November Thursday 21st November Thursday 28th November Thursday 5th December Thursday 12th December Canolfan Elfed, Carmarthen (12-19 years)* Tuesday 1st October Tuesday 8th October Tuesday 15th October Tuesday 22nd October Tuesday 5th November Tuesday 12th November Tuesday 19th November Tuesday 26th November Tuesday 3rd December Tuesday 10th December Myrddin Unit, Carmarthen (5-11 years)* Wednesday 2nd October Wednesday 9th October Wednesday 16th October Wednesday 6th November Wednesday 13th November Wednesday 20th November Wednesday 27th November Wednesday 4th December Wednesday 11th December Saturday Club, Johnstown Centre, Carmarthen (12-19 years)* Saturday 28th September Saturday 5th October Saturday 12th October Saturday 19th October Saturday 2nd November Saturday 9th November Saturday 16th November Saturday 23rd November Saturday 7th December Saturday 14th December Saturday 21st December Saturday Club, Caemaen Centre, Llanelli (12-19 years)* Saturday 28th September Saturday 5th October Saturday 12th October Saturday 19th October Saturday 2nd November Saturday 9th November Saturday 16th November Saturday 23rd November Saturday 7th December Saturday 14th December Saturday 21st December 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
