Attendees Form

• Ticket Name

  Your details

  Name

  Email

  Address Line 1*

  Address Line 2*

  Address Line 3

  Town/City*

  County

  Postcode*

  Home Telephone Number*

  Work Telephone Number

  Mobile Telephone Number

  Relationship to child with vision impairment Mother Father Guardian/carer Other

  if "Other", please give details

  Where did you first hear about NCW? Search Engine VI Support Charity Social Media Facebook Social Media Twitter Social Media Instagram Social Media LinkedIn Sight Village Exhibition Central Sight Village Exhibition London Sight Village Exhibition Manchester / Leeds Sight Village Exhibition Devon Sight Village Exhibition Wales Exhibition / Event (not Sight Village) Third party event at NCW Advertisement Email from NCW PR (media article – radio/TV/magazine/newspaper) Local Authority contact QTVI in mainstream school SENCo in mainstream school Teacher Teaching Assistant in mainstream school Recommendation from another family NCW student Parent of current NCW student Other

  More information about where you first heard about NCW

  Mailing List Yes please keep me on your mailing list – I would like to hear about news and events at NCW

   

  Details of child with vision impairment

  Name of child*

  Date of Birth*

  Print format Standard Print Braille Large Print (N18) Large Print (N18) bold Large Print (N24) Large Print (N24) bold Other Size

  Details of vision impairment

  Name of Current School

  Address of Current School

  Name of Contact at Current School

  Email of Contact at Current School

  Special Dietary Requirements Vegetarian Vegan Dairy free Gluten free Halal Nut allergy Other

  Special Dietary Requirements: Other/Comments

   

  Medial Overview

  All information will be treated with the strictest confidence, shared only with NCW medical and care staff where necessary to ensure the wellbeing of the child.

  Eye Condition

  Registered Severely Sight Impaired Sight Impaired Neither

   

  Family Doctor

  Name of Doctor

  Practice Name

  Practice Telephone Number

  Practice Address

   

  Allergies

  If necessary do we have your permission to administer painkillers such as paracetamol or aspirin? Yes No

  Details of any Allergies

   

  Medications

  Medication #1

  Name of Medication

  Dose

  Times to be Taken

  Self-Adminstered Yes No

  Medication #2

  Name of Medication

  Dose

  Times to be Taken

  Self-Adminstered Yes No

  Medication #3

  Name of Medication

  Dose

  Times to be Taken

  Self-Adminstered Yes No

  Medication #4

  Name of Medication

  Dose

  Times to be Taken

  Self-Adminstered Yes No

  Medication #5

  Name of Medication

  Dose

  Times to be Taken

  Self-Adminstered Yes No

   

  Mental Health

  For safeguarding reasons it is essential that we are aware of any other medial issues, including mental health related issues – so that we can make any necessary arrangements to ensure that your child has the best possible experience while he or she is with us.

  Details of any issues around mental health and well being

  Seen by a professional in last 2 years? Yes No

  if Yes please give details

   

  Additional Details

  We require this information in order to be able to undertake an appropriate risk assessment.

  Additional difficulties, medical conditions or special aids?

  Any other relevant health information

   

  Personal information related to care

  All information will be treated with the strictest confidence, shared only with NCW medical and care staff where necessary to ensure the wellbeing of the child.

   

  Diet

  Describe your child’s appetite Good Poor Variable

  Does your child have very specific dietary likes or dislikes? Yes No

  If Yes, please describe

   

  Personal Care

  Is your child independent in their care? If Yes please tick... Wash and shower Toileting Brush teeth Wash hair Shave Manage personal hygiene Use sanitary products Dress/undress Use knife and fork Pour a drink

  Any other useful information with regard to personal care.

  Any other information that would be useful to staff in the care of your child

  There may be guide dogs or other animals on campus. Please let us know if your child is unhappy around any animals and give details

  Please use this space to add any other information you feel may be relevant to us in order to ensure your child’s stay is a happy one. The more information we have, the more rewarding we can ensure your child’s stay at NCW will be.

   

  Personal information related to activities

  All information will be treated with the strictest confidence, shared only with NCW medical and care staff where necessary to ensure the wellbeing of the child.

  Any activities which should be avoided for medical reasons?

  Any special precautions to be taken before or whilst undertaking activities?

  Swimming Ability Can’t swim Weak swimmer (less than one length) Strong swimmer (more than one length without stopping)

  Diving Ability Can confidently jump/dive into deep water Cannot confidently jump/dive into deep water

   

  Preferences

  Please outline activities or hobbies that your child likes to do in their spare time

  Is your child involved in any community groups such as Guides, Scouts, sports clubs etc...?

  I agree to my child participating in the following activities Archery Bushcraft/forest school Climbing (indoor/outdoor) Dance Fitness activities such as Yoga / Zumba / Circuit Training / Fitness Sessions Free swim sessions General leisure trips such as cinema / ten-pin bowling / tourist sites / museums / sports stadiums / shopping / safari park / days out / etc... Ice skating Martial arts coaching such as judo / karate / etc... Tandem bike riding Theme parks Walks

  I agree for my child to travel in an NCW vehicle Yes No

  Purchase Order Number (Optional)

  Mailing List* Yes please - keep me on your mailing list. I would like to hear about news and events at NCW. Your information will not be shared with third parties No thank you - I do not wish to be contacted