Enable Me Disability Sports Registration Form
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Your name:
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Name of Child:
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Your relationship to the child:
Parent
Guardian
Carer
Teacher
Other
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Date of Birth of Child:
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What school does the child attend?:
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What is the child's year group?:
Reception
Year 1
Year 2
Year 3
Year 4
Year 5
Year 6
Year 7
Year 8
Year 9
Year 10
Year 11
Year 12
Year 13
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Where does the child live?:
0/255 characters
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Would the child like to bring a friend or sibling to the session?:
Yes
No
If you answered yes above, what is the name of the friend or sibling?:
What is the age of the friend or sibling?:
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What is the child's disability?:
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Broadly speaking, which of the categories below does the child's disability fall into?:
Manual Wheelchair User
Electric Wheelchair User
Social/Communication Difficulties
Ambulant
Other Learning Difficulties
Emotional and Behavioural Difficulties
Sensory impairment
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Is the child in receipt of either the medium or higher rate care component of the Disability Living Allowance (DLA)?:
Yes
No
Unsure
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Will you want to attend the sessions with the child?:
Yes
No
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Does the child have any specialised medical needs?:
Yes
No
If you answered 'yes' to the above question then please write details of needs here.
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Does the child have any specialised care needs?:
Yes
No
If you answered 'yes' to the above question then please write details of needs here.
Is there anything else you feel we should know?:
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Please fill in your email address so we can contact you with further details:
If you prefer we contact you by phone then please enter your phone number below:
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Are you happy for us to use any images or video footage of your child taking part in the sports activities for our publicity purposes?
Yes
No
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