Inclusive pre-activity support

1
Individuals name* This field is required.
First Name
Last Name
2
Their age bracket:* This field is required.
0-4 years
5-12 years
13-19 years
20-25 years
26+
3
Is the young person currently in education?* This field is required.
Yes, mainstream
Yes, specialist provision
Home education
No, not currently in any kind of education
4
Where do they attend?
5
Does the young person require 1:1 or 2:1 support in education?* This field is required.
1-1
2-1
No
6
Does the young person currently access any therapy support in Stockport?* This field is required.For example occupational therapy, physio, counselling
YESNO
7
Who provides the therapy, and do you consent for us getting in contact with them?This may help with the support we can offer.
Huge
Large
Normal
Small
Ok
Ok
8
Does the young person require 1:1 or 2:1 support socially/during extra curricular activities?* This field is required.
1-1
2-1
No
9
Does the young person have a diagnosis and/or disability that we need to be made aware of?* This field is required.
Yes
No
10
Please inform us of the diagnosis and/or disability(s) in as much detail as possible:This will help us to support the young person into the most appropriate opportunities and activities.
11
In order for us to understand more about the young person, please tick as many as are appropriate:* This field is required.
Has a visual impairment
Has a hearing impairment
May behave unpredictably (eg shuts down, hides, absconds, can be physical)
Prefers verbal communication
Uses PECS
Signs using Makaton or BSL
Is comfortable in busy environments
Is not comfortable in busy environments, prefers quiet
12
Child likes and dislikes?* This field is required.
13
Worst case scenario. Please describe the most extreme behaviour your child will display if they are very upset/stressed. * This field is required.
14
Please add any additional information on how we can best accommodate your child and make sure they have the best time (eg please detail any social support your child might need)? * This field is required.
15
Please let us know what type of activity you are interested in:* This field is required.Tick as many as you like
Sport specific
Health and wellbeing
General physical activity
Holistic activity
Strength, mobility and fitness
Social and play
Swimming and pool based
Targeted activity
Girls and young women
16
Please provide your email address so that we can send over relevant information* This field is required.By doing so you consent for us to contact you
example@example.com
17
Please provide your phone number* This field is required.By doing so you consent for us to contact you
Please enter a valid phone number.
Should be Empty: