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: OTHER INFORMATION is optional - If you are happy to share any demographic data with us please complete the Other Information section below. This enables us to contact you about the things that are more relevant to you and helps with our diversity monitoring.

By post

By email

By mobile

By text message

Receive newsletters

Other information

I can confirm that I have a child/children aged 0-25 with additional needs

Year of birth of my youngest child with additional needs

Parent/Carer Date of Birth

Gender

Gender other

Identify as gender assigned at birth

Sexuality

Sexuality other

Ethnicity

Ethnicity other

Religion

Religion other

Preferred Language (if not English)

Parent/Carer disability?

Are you a Lone parent?

Are you/Have you been in the Armed forces?

Are your children entitled (means tested) Free school meals?

Are you an Adoptive parent?

Are you a Foster/Kinship carer?

Are you a Member of the Gypsy, Roma or Traveller community?

Is there anything else you would like to share with us about yourself, your child or your experiences?

We have many opportunities for parent carers to be involved in our work - please tick here if you would like us to send you more information

Child 1 Birth Month

Child 1 Birth Year

Child 1 Needs/Disability

Attention Deficit Hyperactivity Disorder (ADHD)

Autistic

Blood Disorder

Brain Injury

Celebral Palsy

Chronic Fatigue Syndrome/ME

Cystic Fibrosis

Chronic Neurological Condition

Down Syndrome

Dyscalculia

Dyslexia

Dyspraxia

Epilepsy

Genetic condition

Global Development Delay

Hearing Impairment

Hypermobility

Medical Needs

Mental Health Conditions

Mobility Difficulties

Moderate Learning Difficulties (MLD)

Muscular Dystrophy

Physical Disability

Profound and Multiple Learning Difficulties (PMLD)

Selective Mutism

Sensory Processing Difficulties

Social, Emotional, Mental Health Difficulties

Spina Bifida

Severe Learning Difficulties

Tourettes

Unknown/Awaiting Diagnosis

Visual Impairment

Other

N/A

Child 1 Needs/Disability other

Child 2 Birth Month

Child 2 Birth Year

Child 2 Needs/Disability

Attention Deficit Hyperactivity Disorder (ADHD)

Autistic

Blood Disorder

Brain Injury

Cerebral Palsy

Chronic Fatigue Syndrome/ME

Chronic Neurological Condition

Cystic Fibrosis

Down Syndrome

Dyslexia

Dyspraxia

Dyscalculia

Epilepsy

Genetic condition

Global Development Delay

Hearing Impairment

Hypermobility

Medical Needs

Mental Health Conditions

Mobility Difficulties

Moderate Learning Difficulties (MLD)

Muscular Dystrophy

Physical Disability

Profound and Multiple Learning Difficulties (PMLD)

Selective Mutism

Sensory Processing Difficulties

Severe Learning Difficulties

Social, Emotional, Mental Health Difficulties

Spina Bifida

Tourettes

Visual Impairment

Unknown/Awaiting Diagnosis

Other

Child 2 Needs/Disability other

Child 3 Birth Month

Child 3 Birth Year

Child 3 Needs/Disability

Attention Deficit Hyperactivity Disorder (ADHD)

Autistic

Blood Disorder

Brain Injury

Cerebral Palsy

Chronic Fatigue Syndrome/ME

Chronic Neurological Condition

Cystic Fibrosis

Down Syndrome

Dyslexia

Dyspraxia

Dyscalculia

Epilepsy

Genetic condition

Global Development Delay

Hearing Impairment

Hypermobility

Medical Needs

Mental Health Conditions

Mobility Difficulties

Moderate Learning Difficulties (MLD)

Muscular Dystrophy

Physical Disability

Profound and Multiple Learning Difficulties (PMLD)

Selective Mutism

Sensory Processing Difficulties

Severe Learning Difficulties

Social, Emotional, Mental Health Difficulties

Spina Bifida

Tourettes

Visual Impairment

Unknown/Awaiting Diagnosis

Other

Child 3 Needs/Disability other

Child 4 Birth Month

Child 4 Birth Year

Child 4 Needs/Disability

Attention Deficit Hyperactivity Disorder (ADHD)

Autistic

Blood Disorder

Brain Injury

Cerebral Palsy

Chronic Fatigue Syndrome/ME

Chronic Neurological Condition

Cystic Fibrosis

Down Syndrome

Dyslexia

Dyspraxia

Dyscalculia

Epilepsy

Genetic condition

Global Development Delay

Hearing Impairment

Hypermobility

Medical Needs

Mental Health Conditions

Mobility Difficulties

Moderate Learning Difficulties (MLD)

Muscular Dystrophy

Physical Disability

Profound and Multiple Learning Difficulties (PMLD)

Selective Mutism

Sensory Processing Difficulties

Severe Learning Difficulties

Social, Emotional, Mental Health Difficulties

Spina Bifida

Tourettes

Visual Impairment

Unknown/Awaiting Diagnosis

Other

Child 4 Needs/Disability other

I have more than 4 children with additional needs

My child(ren) detailed above have sibling(s) with no additional needs

IMPACT are the young people's participation group for SEND - please tick here if you would like us to send you more information for your child

By clicking "Submit" you agree that your information will be collected and processed by Warwickshire Parent Carer Voice in accordance with our privacy policy. Your data will be stored securely and will not be shared with any third party without your consent. You have the right to access, or request deletion of your personal data by contacting us.

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