AAATEST

Which youth group would your child like to attend?

Bracknell CAYP Youth GroupReading Games ClubWoolhampton Lego Club

Has your child ever attended an Autism Berkshire youth group before?

YesNo

If my child is offered a place, I agree that they will attend all sessions, and that if my child does not attend regularly, their place may be given to another child on the waiting list. Each case will be considered on an individual basis if, for example, your child is ill.

I agree.

Have you/do you access any other activities that Autism Berkshire offers?

HelplineDrop in sessionsBenefits advice appointmentHome visitsWorkshops/TrainingSupport GroupsThames Valley Adventure PlaygroundOne off trips with Autism BerkshireTrampoliningSwimming

Parent/carer (main contact) first name:

Parent/carer (main contact) last name:

Address:

Postcode:

Parent/carer email address:

Parent/carer telephone number:

Tick the box that best describes you

I am the parent of the childI am the guardian/carer of the child

Child's first name:

Child's last name:

What is your child's age?

What is your child's date of birth?

What is your child's gender?

—Please choose an option—FemaleMaleNon-binaryPrefer not to say

Which school does your child attend?

Can your child manage well in a 1:4, staff:child situation?

YesNoOther:

If no, please provide some more details about the support your child needs

Does your child have an Autism diagnosis?

—Please choose an option—YesNo, they are currently on the Autism Assessment Pathway at CAMHSNo

Please provide a date of diagnosis if your child has been diagnosed.

Does your child have any additional health needs? Please provide some details.

I am happy for my child to receive first aid or emergency medical treatment by trained Autism Berkshire staff or medical authorities.

I agreeI do not agreeOther:

Please list any activities your child enjoys/attends.

What are your child's interests?

Please describe any difficulties your child has with communication.

Does your child often become physically or verbally aggressive?

—Please choose an option—YesNoVery Occasionally

If yes, please provide details.

Does your child abscond from settings or people (e.g. school, home or groups)?

—Please choose an option—YesNo

If yes, please provide details.

How did you hear about Autism Berkshire?

[select* hear_about include_blank "Autism Berkshire Website" "CAMHS" "Local Offer" "Word of mouth" "Through one of our other services" "At a local event, e.g. fundraiser, fete]

Data Protection

I consent to my child having photographs/videos taken for use in publicity for Autism Berkshire and the NHS.

I consentI do not consent

Data Protection (please tick all that apply):

I agree for my data to be stored for the purposes of reporting on the project activity and spend to BBC Children in NeedI agree for my data to be used to keep my up-to-date through the Autism Berkshire newsletterI agree for my data to be used to contact me about training, workshops and courses.I agree for my data to be used to contact me about children's and family leisure activities.I agree for my data to be used to contact me about fundraising.I agree for my data to be used to contact me about volunteering.Other:

I am happy to be contacted by (please tick all that apply):

EmailTelephonePost

Your confirmation:

I understand that by submitting this form I am giving Autism Berkshire consent to store my data and use it to contact me in the ways that I have indicated and for analysis and monitoring purposes.

Privacy Notice

We will always store you personal data securely. We will use them to communicate with you and to provide any service that you have requested. Your data may also be used for analysis purposes to help us provide the best possible service and for monitoring purposes by our funders. We will only share it if it is required to do so by law.

For details of our Data Protections Policy, please see our website at www.autismberkshire.org.uk.

A copy of your responses will be emailed to the address that you provided.

Parent/Carer first name:

Parent/Carer last name:

Email address

Telephone number

Child first name:

Child last name:

Child's age:

Address:

Postcode:

 

We run 3 trampolining sessions at Meadway Sports Centre, Crosfields School and Bracknell Trampoline Centre. Which of these sessions would you like to go on the waiting list for? (Check all that apply) *

Meadway Sports CentreCrosfields SchoolBracknell Trampoline Centre

 

Which venue would you prefer when a space becomes available?

Meadway Sports CentreCrosfields SchoolBracknell Trampoline Centre

 

My child... *

—Please choose an option—has an autism diagnosis.is on the pathway with CAMHS.does not have autism

 

Does your child have any additional needs we need to be aware of? E.g. are they non-verbal? do they tend to abscond? do they need visual cues to communicate?

 

Please add me to a mailing list

All details will be treated as confidential and will not be shared or passed on to other parties without your knowledge and consent