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% Todays date* Date Format: DD slash MM slash YYYY Well-Being InformationHave you been advised that your child needs to 'shield'?*YesNoHas your child attended any of the School Hubs?*YesNoIf Yes, which Hub?Has your child attended any of the respite centres? (i.e. Llys Caradog or Blaenau)*YesNoCommentsHave you received any other support since the start of the restrictions?*YesNoCommentsChild's InformationChild's Full Name*Child's Gender*MaleFemaleDate of Birth* Date Format: DD slash MM slash YYYY Address*This is Me*Please upload a photograph of your childParent & Carer InformationParent/Carer Name*Parent/Carer Address (if different)Home Telephone Number*Work Telephone NumberMobile Telephone Number*Email Address Name of SchoolGP Surgery InformationGP Surgery Name*GP Surgery Address*GP Phone Number*Is your child on prescribed medication?*YesNo BookingBooking is open for the Summer Holiday Clubs 2020. Bookings will re-open for the After School and Saturday Clubs at a later date.I would like my child to attend these clubs* Summer Club, Heol Goffa, Llanelli (5-11 years) Summer Club, Heol Goffa, Llanelli (12 - 19 years) Summer Club, Canolfan Elfed, Carmarthen (12-19 years) Summer Club, Myrddin Unit, Carmarthen (5-11 years) Summer Club, Llandybie Hall, Ammanford (12-19 years) Heol Goffa (week 1) Tuesday 4th August - 9.00 am - 12.30 pm (ages 12 - 19 years) Tuesday 4th August - 1.30 pm - 5.00 pm (ages 12 - 19 years) Wednesday 5th August - 9.00 am - 12.30 pm (ages 12 - 19 years) Wednesday 5th August - 1.30 pm - 5.00 pm (ages 12 - 19 years) Thursday 6th August - 9.00 am - 12.30 pm (ages 5 - 11 years) Thursday 6th August - 1.30 pm - 5.00 pm (ages 5 - 11 years) Half day sessions only Heol Goffa (week 2) Tuesday 11th August - 9.00 am - 12.30 pm (ages 12 - 19 years) Tuesday 11th August - 1.30 pm - 5.00 pm (ages 12 - 19 years) Wednesday 12th August - 9.00 am - 12.30 pm (ages 12 - 19 years) Wednesday 12th August - 1.30 pm - 5.00 pm (ages 12 - 19 years) Thursday 13th August - 9.00 am - 12.30 pm (ages 5 - 11 years) Thursday 13th August - 1.30 pm - 5.00 pm (ages 5 - 11 years) Half day sessions only Heol Goffa (week 3) Tuesday 18th August - 9.00 am - 12.30 pm (ages 12 - 19 years) Tuesday 18th August - 1.30 pm - 5.00 pm (ages 12 - 19 years) Wednesday 19th August - 9.00 am - 12.30 pm (ages 12 - 19 years) Wednesday 19th August - 1.30 pm - 5.00 pm (ages 12 - 19 years) Thursday 20th August - 9.00 am - 12.30 pm (ages 5 - 11 years) Thursday 20th August - 1.30 pm - 5.00 pm (ages 5 - 11 years) Half day sessions only Heol Goffa (week 4) Tuesday 25th August - 9.00 am - 12.30 pm (ages 12 - 19 years) Tuesday 25th August - 1.30 pm - 5.00 pm (ages 12 - 19 years) Wednesday 26th August - 9.00 am - 12.30 pm (ages 12 - 19 years) Wednesday 26th August - 1.30 pm - 5.00 pm (ages 12 - 19 years) Thursday 27th August - 9.00 am - 12.30 pm (ages 5 - 11 years) Thursday 27th August - 1.30 pm - 5.00 pm (ages 5 - 11 years) Half day sessions only Canolfan Elfed (week 1) Monday 3rd August - 9.00 am - 12.30 pm (ages 12 - 19 years) Monday 3rd August - 1.30 - 5.00 pm (ages 12 - 19 years) Tuesday 4th August - 9.00 am - 12.30 pm (ages 12 - 19 years) Tuesday 4th August - 1.30 pm - 5.00 pm (ages 12 - 19 years) Wednesday 5th August - 9.00 am - 12.30 pm (ages 12 - 19 years) Wednesday 5th August - 1.30 pm - 5.00 pm (ages 12 - 19 years) Half day sessions only Canolfan Elfed (week 2) Monday 10th August - 9.00 am - 12.30 pm (ages 12 - 19 years) Monday 10th August - 1.30 - 5.00 pm (ages 12 - 19 years) Tuesday 11th August - 9.00 am - 12.30 pm (ages 12 - 19 years) Tuesday 11th August - 1.30 pm - 5.00 pm (ages 12 - 19 years) Wednesday 12th August - 9.00 am - 12.30 pm (ages 12 - 19 years) Wednesday 12th August - 1.30 pm - 5.00 pm (ages 12 - 19 years) Half day sessions only Canolfan Elfed (week 3) Monday 17th August - 9.00 am - 12.30 pm (ages 12 - 19 years) Monday 17th August - 1.30 - 5.00 pm (ages 12 - 19 years) Tuesday 18th August - 9.00 am - 12.30 pm (ages 12 - 19 years) Tuesday 18th August - 1.30 pm - 5.00 pm (ages 12 - 19 years) Wednesday 19th August - 9.00 am - 12.30 pm (ages 12 - 19 years) Wednesday 19th August - 1.30 pm - 5.00 pm (ages 12 - 19 years) Half day sessions only Canolfan Elfed (week 4) Monday 24th August - 9.00 am - 12.30 pm (ages 12 - 19 years) Monday 24th August - 1.30 - 5.00 pm (ages 12 - 19 years) Tuesday 25th August - 9.00 am - 12.30 pm (ages 12 - 19 years) Tuesday 25th August - 1.30 pm - 5.00 pm (ages 12 - 19 years) Wednesday 26th August - 9.00 am - 12.30 pm (ages 12 - 19 years) Wednesday 26th August - 1.30 pm - 5.00 pm (ages 12 - 19 years) Half day sessions only Myrddin Unit (week 1) Monday 3rd August - 9.00 am - 12.30 pm (ages 5 - 11 years) Monday 3rd August - 1.30 - 5.00 pm (ages 5 - 11 years) Tuesday 4th August - 9.00 am - 12.30 pm (ages 5 - 11 years) Tuesday 4th August - 1.30 pm - 5.00 pm (ages 5 - 11 years) Wednesday 5th August - 9.00 am - 12.30 pm (ages 5 - 11 years) Wednesday 5th August - 1.30 pm - 5.00 pm (ages 5 - 11 years) Half day sessions only Myrddin Unit (week 2) Monday 10th August - 9.00 am - 12.30 pm (ages 5 - 11 years) Monday 10th August - 1.30 - 5.00 pm (ages 5 - 11 years) Tuesday 11th August - 9.00 am - 12.30 pm (ages 5 - 11 years) Tuesday 11th August - 1.30 pm - 5.00 pm (ages 5 - 11 years) Wednesday 12th August - 9.00 am - 12.30 pm (ages 5 - 11 years) Wednesday 12th August - 1.30 pm - 5.00 pm (ages 5 - 11 years) Half day sessions only Myrddin Unit (week 3) Monday 17th August - 9.00 am - 12.30 pm (ages 5 - 11 years) Monday 17th August - 1.30 - 5.00 pm (ages 5 - 11 years) Tuesday 18th August - 9.00 am - 12.30 pm (ages 5 - 11 years) Tuesday 18th August - 1.30 pm - 5.00 pm (ages 5 - 11 years) Wednesday 19th August - 9.00 am - 12.30 pm (ages 5 - 11 years) Wednesday 19th August - 1.30 pm - 5.00 pm (ages 5 - 11 years) Half day sessions only Myrddin Unit (week 4) Monday 24th August - 9.00 am - 12.30 pm (ages 5 - 11 years) Monday 24th August - 1.30 - 5.00 pm (ages 5 - 11 years) Tuesday 25th August - 9.00 am - 12.30 pm (ages 5 - 11 years) Tuesday 25th August - 1.30 pm - 5.00 pm (ages 5 - 11 years) Wednesday 26th August - 9.00 am - 12.30 pm (ages 5 - 11 years) Wednesday 26th August - 1.30 pm - 5.00 pm (ages 5 - 11 years) Half day sessions only Llandybie Hall (week 1) Thursday 6th August - 10.00 am - 2.00 pm (ages 12 - 19 years) Friday 7th August - 10.00 am - 2.00 pm (ages 12 - 19 years) Llandybie Hall (week 2) Thursday 13th August - 10.00 am - 2.00 pm (ages 12 - 19 years) Friday 14th August - 10.00 am - 2.00 pm (ages 12 - 19 years) Llandybie Hall (week 3) Thursday 20th August - 10.00 am - 2.00 pm (ages 12 - 19 years) Friday 21st August - 10.00 am - 2.00 pm (ages 12 - 19 years) Llandybie Hall (week 4) Thursday 27th August - 10.00 am - 2.00 pm (ages 12 - 19 years) Friday 28th August - 10.00 am - 2.00 pm (ages 12 - 19 years) 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 happy*What makes me sad*Please 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 Photograph*If 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 Number*First 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 Photograph*If 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*YesNoTime : HH MM AM PM Date Date Format: MM slash DD slash YYYY Date Date Format: MM slash DD slash YYYY UntitledFirst ChoiceSecond ChoiceThird ChoiceUntitledNumber
