Additional Needs Form Child's detailsFirst Name*Last Name*Any other name that they are known by:PhotoGender*MaleFemaleDate of birth* Age at Spring HarvestYoung people in the 11-14s and 15+ programmes are free to come and go as they wish. If you have a child in the youth programme and they are not safe leaving the venue alone, please arrange to meet them during their morning break time and at the end of the programme.Emergency Mobile Phone Number*Responsible adultRelationshipGuardianParentFull Name* First Last Email* Home Address and Postcode* Daytime PhoneEvening PhoneMobile PhoneWhich break are you going to in 2016? Skegness (28 March - 1 April) Minehead One (28 March - 2 April) Minehead Two (2-6 April) Minehead Three (6 - 10 April) We shall attend as:Part of an organised groupA family or group of friendsDay VisitorsPart of the Spring Harvest teamUnsure, but hope to attendGroup organiser's nameDays we will attendWhich Spring Harvest team? My child has attended Spring Harvest before When or other details My child has siblings in the child or youth programme Names and ages of siblings Are you the person who is going to be responsible for this child at Spring Harvest?YesNoAdult in ChargeName First Last Daytime Phone numberEvening Phone numberMobile Phone numberRelationship to the childLevel of support neededOur resources are finite and the availability of team members with the huge variety of skills required is also a limiting factor so we may not be able to meet the needs of every child and are not able to offer one-to-one support. At first we may ask you to stay with your child until the team is confident that he or she has settled or until the leaders are satisfied they can provide good care.Under normal circumstances, how does your child function in a small group: Needs no support Needs some support Needs a high level of support Receives support at school or church My child needs One-to-one care Level of support that school or church offersPlease note that we are unable to provide one-to-one care so if your child needs that level of support a family member or trusted friend may accompany them in the programmePlease name each carer who will support your child at Spring HarvestCarer One First Name Last Name Carer Two First Name Last Name Carer Three First Name Last Name Carer Four First Name Last Name Physical issues My child uses a wheelchair My child has difficulties with balance and may find stairs difficult My child will or may need help with toileting and I give permission for an approved member of the Spring Harvest team to assist them in this way (please tell us more about the help which may be needed in the space below) My child will or may need help with toileting and I do not give permission for Spring Harvest team members to give such assistance and will accompany my child in their programme My child may need reminding to go to the toilet Space for any other information about your child's physical needs that we should be aware of. Communication needs and learning difficulties My child has difficulties hearing and instructions may need to be repeated My child uses a hearing aid My child is deaf My child uses Makaton or BSL (if so, please give more information in the box below) My child uses the following form of communication. My child has severe visual impairment, worksheets etc need to be in a large print My child is blind My child uses a communication board or book My child has speech some may find difficult to understand My child has difficulty reading and writing -- is significantly below the level expected at their age My child needs instructions repeated and simplified My child has been diagnosed on the autistic spectrum Space for more information about your child's communication or learning needs, including their ability to follow instructions and any non-verbal communication they use. (It may be possible to provide some resources in advance, such as large print song words, but only if sufficient notice is given). Behvioural issuesPlease tick any of the following which apply to your child My child is very shy with new people, especially in groups My child is likely to wander if not engaged in the programme My child may become aggressive in unfamiliar situations My child would appreciate a cuddle if upset Do not cuddle if upset, it may frighten my child further My child has been diagnosed with ADHD Behavioural issues will not usually exclude a child from the programme, but it is essential we are aware of them.The following activities or situations may upset or frighten my child: Space for other information about your child's behaviour which we should be aware of, including the best way to comfort or reassure them. Medical conditionsSpring Harvest Team are not medically trained and cannot be responsible for ensuring medication is taken at specific times. In a medical emergency they will ask Butlins to provide medical assistance and try to contact you immediately. Designated team members have received basic instruction in the storage and administration of epi-pens. Children who can and do administer their own medication, such as an inhaler, may do so as required within the programme. Please tick any of the following which apply to your child My child carries an asthma inhaler. My child carries an epi-pen. Who will have the inhaler during the programme? In normal settings and I am happy for my child to have it with them in the programme and administer it when appropriate They will need assistance to administer it. I give permission for a designated team member to offer such assistance Who will have the Epi-pen during the programme? My child will hold the epi-pen during the programme I would like the epi-pen to be held by a designated team member during the programme It is the responsibility of the parent/guardian to bring the epi-pen, give it to and collect it from the identified team member at the beginning of each session. Epi-pens must NOT be left with team members outside programme hours.What should we do in a medical emergency? I give permission for the epi-pen to be administered by a nominated and trained team member If it is resonably considered that any delay in administering the epi-pen would create a significant risk to the health of my child. Please do not administer my child's epi-pen, but please do the following... Other medical conditions Please give details of any medical conditions that we should be aware of, the dosage and possible side effects of any medication and information about your child's awareness of their condition. Name and phone number of GP If your child has a medical condition which may require attention at Spring Harvest please give GP details.Other informationIf your child needs support for any other reason, please click the box below and give a brief description of their situation. You can also use this space for anything else you would like us to be aware of, including any subjects or topics that may upset them. Display comments box Thank you for completing this form. When you click Send Form you will be taken to a new screen. If that does not happen please check back over the form as it probably means you have missed out an important question. An email will then be sent to you with the information you have put here and a copy of that email will be sent to the Spring Harvest office.