Little Treasures Expression of Interest

First name

Last name

Address 1

Address 2

Address 3

Postcode

Email address

Mobile phone

Please agree to SGPC contacting you by email/mobile/text by ticking the boxes below. This will enable us to contact you regarding the waiting list. We will also be able to send details of new workshops, reminders of bookings/activities, weekly news and other updates. We do not share your details with any third parties. Do you agree to us contacting you:

By post

By email

By mobile

By text message

Other information

Parent Carer Details

Ethnic Origin

If other Ethnic Origin, please state

How many children do you have with additional needs?

Do you consider yourself a carer?

Any disability

Date of Birth

Your Gender

If other Gender, please state

Details about your child or children

Child First Name

Child Surname

Child 1: Date of Birth

Name of Education Setting/School

Child 1: Does your child have any medical needs or allergies?

Child 1: If medical need/allergy, please state

Additional Needs/Disability of children

Unsure

Prefer not to say

Undiagnosed

ADHD/ADD

Autism (this includes Aspergers/PDA)

Chronic Fatigue Syndrome/ME

Down Syndrome

Dyslexia

Dyspraxia/Coordination/Hypermobility

Genetic/Chromosome Disorder

Global Development Delay

Hearing Impairment

Learning Difficulties Moderate (MLD)

Learning Difficulties Severe (SLD)

Learning Difficulties Profound Multiple (PMLD)

Medical/Health Needs

Multi-Sensory Impairment

Neurological disorder (Cerebral Palsy/Epilepsy/Hydrocephalus/Brain injury)

Physical Disability

Speech and Language

Sensory Processing Needs

Social Emotional Mental Health Needs (Anxiety/OCD/Trauma/Attachment)

Social Communication Needs

Syndrome without a name

Visual Impairment

Other

If Other, please state

Current Educational Support Needs

Which Stay and Play group would you be able to attend?

Thanks for completing our expressions of interest form. When we have a space we will be in touch to find out more about your child. Meanwhile please check out our website and find out what we offer to families https://sgpc.org.uk

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