Lamplight API response

First name

Last name

Address 1

Address 2

Address 3

Address 4

Address 5

Postcode

Email address

Mobile phone

Phone number

We would like to contact you about our services from time to time. You can opt out whenever you like, and we won't share your contact details with any other organisations. Are you happy for us to contact you (please tick any that apply):

By post

By email

By mobile

By text message

Other information

Gender/ Prefered pronouns

Does your child go by any other name?

Date of birth

Does your child attend school or college?

Name of school/college

Contact Information

Name of Parent/Guardian

Email Address of Parent/Guardian

Telephone Number of Parent/Guardian

Name of Second Parent/Guardian/Contact

Email Address of Second Parent/Guardian/Contact

Telephone Number of Second Parent/Guardian/Contact

Emergency Contacts - please list

Authorised Pick up/drop off - please list names

Medical Information

GP's name

GP's address and postcode

GP's tel No

Does your child have an autism diagnosis?

Does your child have any other conditions and/or disabilities?

If yes - details

Does your child have epilepsy?

Does your child have any allergies?

If yes - details

Does your child have asthma?

What, if any, medication does your child use?

Consent to administer medication received

Is there anything else about your childs physical or mental health that you think we should know about?

Intimate Care

Does your child need help at the toilet and with personal care?

If yes - give details

Does your child use nappies?

If yes, what is the normal nappy changing routine?

Has your child started their period?

If yes - what support do they need?

Does your child need help dressing and undressing?

If yes - details

Communication

What languages does your child use and understand?

Please describe how your child communicates

Does your child use any form of sign language or visual aid?

If yes - details

Makaton

PECS

BSL

Signalong

Are there other ways we can communicate with your child?

If yes - please describe

Are there any situations where your child may use inappropriate language?

Does your child currently have their own mobile phone? If yes what guidelines are in place for its use?

Does your child require support with maintaning appropriate boundaries and healthy relationships with those around them?

Food and Drink

Is your child on a special diet?

If yes - details of diet

Are there any foods or drinks your child should avoid?

If yes - list

Can your child eat and drink unaided?

If No - what help does your child need?

Does your child understand the risks of being in a kitchen?

Are there any risks to your child with eating and drinking?

Likes and Dislikes

Details of any special interests your child has

Examples of things your child LIKES

Examples of things your child DISLIKES

Please give examples of places your child likes to visit.

Please give examples of places your child does not like to visit

Behaviour support plan

How do you promote positive behaviour in your child

Are there particular triggers that upset your child?

Are there any particular signs or mannerisms that show your child is becoming upset or disregulated??

Is there any particular approach, technique or routine that is used when introducing (or leaving) a new activity?

If yes - details

Are there any situations where your child may harm another person?

If yes - details of what may provoke this response

Are there any situations where your child may hurt or harm themselves??

If yes - details of what may provoke this response

Describe any other strategies that can be used to best support your child

Does your child have a care/behaviour support plan with any other organisations?

If yes - advise where a copy can be obtained

Activities and Outings

Is your child likely to be self traveling to/from the service?

Do you have any specific concerns with how your child behaves in public spaces?

Are there any activities that your child must NOT take part in (please state what).

Will your child need individual attention to participate in group activities?

Does your child use a booster seat or special harness when using transport?

If yes - details for booster or special harness

Does your child have any specific issues when using public transport?

Does your child have any mobility issues, or experience difficulty in walking moderate distances?

If yes - details of any mobility issues

Has your child ever run away (or attempted to)?

If yes - details of run away attempts

Any other significant information

Are there any risks or concerns with your child and heights?

Are there any risks or concerns with your child attending an overnight residential stay?

Permissions

Outing consent

Outings/activities your child should NOT take part in

I agree for any emergency treatment to be carried out on behalf of my child either at the service venue or at an activity venue

Consent for your child to be included in photos to be used by Branch Out Together on the charity's website/Facebook or twitter pages

Consent for your child to be included in photos that may be used by Branch Out Together for training, marketing and fundraising purposes

Permission for sun cream to be applied to your child

Permission for your child to be taken on public transport

Support Plan Information

Other information

Contact Information

Medical Information

Intimate Care

Communication

Food and Drink

Likes and Dislikes

Behaviour support plan

Activities and Outings

Any other significant information

Permissions