Children's Residential Needs form

Childs Name Attending Residential*

Childs DOB*

Childs Gender*

Parent/Guardian Name*

Name Surname

Address*

Street Address Address Line 2 City Post Code

Relationship to Child*

Telephone Number*

Additional Emergency Contact Name*

Name Surname

Emergency Telephone Number*

Relationship to Child*

Additional Emergency Contact Address*

Adress Address Line 2 City Post Code

Childs GP*

Surname

GP Address*

Street Address Address Line 2 City Post Code

GP Telephone Number

Does Your Child Have a Disability that Once Upon a Smile Should Know About?*

Yes
No

If yes, please provide details of the disability including any help that your child may need.

Does your child suffer from any medical conditions?*

Yes
No

If yes, please provide details of the medical condition and any medication required.

Does your child have any allergies?*

Yes
No

If yes, please provide details of the type of allergy and medication.

Please advise of any dietary requirements (if none, put N/A).*

What activities does your child enjoy / not enjoy?*

For us to ensure your child's stay at The Adventure Fram Trust is as comfortable as possible, please identify any care needs eg; bedwetting, washing, dressing and feeding skills.*

Are there any reasons why your child may become distressed, have challenging behaviour, triggers or phobias? it would be useful to know what steps to take in these situations.*

Would you like to share any further information?

Photograph & Video Declaration.*

At Once Upon a Smile, we love to share the amazing work our children take part in. This can include photographs and video with the possibility of sharing on our social media platforms.

Yes, I agree
No, I do not agree

Declaration*

I agree to the names above being kept on database for tracking and contact purposes. I agree that Once Upon a Smile can share information with other organisations working with myself and my child including education and health.

Declaration*

By clicking this declaration I agree to my child attending The children's Adventure Farm residential trip and confirm I have the relevant authority to consent.

Declaration*

I confirm that I will be available for the duration of the Residential should OUAS need to contact me and/or if I need to collect my child/ren at short notice from The Children's Adventure Farm.

Make a Donation

Children’s Residential Needs form

To ensure we can best support your family, please complete the below form, as soon as possible.