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Please complete all sections fully to enable us to provide the right support and ensure that you can access sessions safely. 

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Holiday Activity and Food (HAF) Inclusive Access Referral Form

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Venues that you have booked sessions at (please tick all that apply)(Required)

Emergency Contact Details

Conditions

Medication

Would your child need to have medication with them during their session?(Required)
This includes inhalers, Epi Pen, rescue medications for seizures, and regular medications or tube feeds etc that would have to be given in sessions
If yes, who would be responsible for holding and administering medication?

Does your child have any personal or medical care needs that we need to be aware of?(Required)
This includes things like being unable to dress/undress without assistance, being unable to use the toilet without help or supervision, incontinence, needing regular checks of blood sugar levels, or any other specific care need.
Please note: Your Trust staff cannot help with personal care or medical care, and so we would ask you or a nominated individual to remain in the building if your child needs support in this area. If your child has these needs, please advise us on who will be supporting them during their session(s)

Does your child have any behavioural issues, whether these are as a result of a disability, a mental health condition, sensory processing disorder, or for any other reason?(Required)
This can include things like meltdowns/overloads, violent behaviour towards themselves, violent behaviour towards staff, being unsafe with scissors or other sharp objects, or being at risk of running away during a session
Your Trust staff will make a decision on each individual case as to whether we can safely provide a session to your child, and we may suggest an alternative session with higher staffing ratios or a different format if we believe that this would be more appropriate.
Please note: safety of everyone involved is paramount, and failure to disclose known behavioural issues may result in exclusion from this session and any future provision.

Other Information Required

Wheelchair User?
If yes, type of chair?
If yes, preferred transfer style?

Preferred communication method?(Required)

Does your child have an assistance dog who would need to attend sessions with them?(Required)
Please note, we will accommodate registered assistance dogs in line with UK law, but we cannot accept emotional support dogs or pets into our centres.

Does your child have any allergies?(Required)

Declaration

(Required)
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