Outreach Application Form Step 1 of 5 20% We are thrilled your child wants to join us on one of our activity days / weekends. Please provide as much information as possible, to ensure your child’s enjoyment and safety.What event are you applying for?*Participant's Name* First Last Any Nickname(s) Date of Birth* Day Month Year Age*School College* Parent / Main Carer's Name* First Last Parent / Main Carer's Email* Parent / Main Carer's Mobile Phone No.*Home Address* Street Address Address Line 2 (Optional) City County (Optional) Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone No.*Emergency ContactName* First Last Relationship* Home Phone No.*Mobile Phone No.*GP SurgerySurgery Name* Surgery Address* Street Address City County Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Surgery Phone No.* Health and Medical needsDiagnosis - please describe your child's condition or disabilityWhat medication, if any, does your child take regularly and how often?Do they need this medication during the activity day / weekend? Yes No N/A At what times of day?Does your child have any major health needs that staff should be aware of?*e.g. epilepsy, asthma, severe allergies etc Yes No Please include full details and send us a Care Plan if appropriateIs your child technology dependent?* Yes No Does your child need to have any emergency medication available at all times?*e.g. inhalers, epipen, epilepsy medication etc... Yes No Please describe the emergency medication requiredAre there any activities that your child should not take part in for medical reasons?e.g. swimming, trampolining, martial arts etc... Personal Care and Hygiene NeedsDoes your child?Please tick as appropriate Manage own personal care independently? Need encouragement or support for personal care? Need practical help with care? e.g. pads changing / cleaning up? Need to use a hoist and changing bed? (Girls) Need help with menstruation? Please give more information if applicableMobilityDoes your child?Please tick as appropriate Walk independently? Use walking aids? Use a wheelchair occasionally? Use a wheelchair permanently? Use an electric wheelchair? Please give more information if applicableMealtimesDoes your child?Please tick as appropriate Manage mealtimes independently? Need supervision or practical help to manage food? Please give more information if applicableDoes your child have any dietary needs relating to serious allergies or medical conditions?e.g. no nuts, gluten-free diet. Please give details...Communication and Sensory NeedsDoes your child?Please tick as appropriate Have a sensory impairment? (Sight / hearing etc...) Have good verbal skills? Use other methods of communication (BSL / Makaton / Communication Aid, PECS)? Please give more information if applicable Behavioural and Emotional NeedsIs your child's behaviour generally reasonable for their age?* Yes No Identify possible triggers and risks, and describe strategies to manage behaviour.Can your child be managed in a small group of 3-4 children?* Yes No Identify possible triggers and risks, and describe strategies to manage behaviour.Does your child usually need constant supervision?* Yes No Identify possible triggers and risks, and describe strategies to manage behaviour.Is your child likely to wander or run off?* Yes No Identify possible triggers and risks, and describe strategies to manage behaviour.Is your child aware of danger?*e.g. water / heights / traffic? Yes No Identify possible triggers and risks, and describe strategies to manage behaviour.Does your child have any strong fears?*e.g. balloons / dogs etc... Yes No Identify possible triggers and risks, and describe strategies to manage behaviour.Does your child have temper tantrums or other strong reactions?* Yes No Identify possible triggers and risks, and describe strategies to manage behaviour.Is your child sexually aware?* Yes No Do they need close supervision when around specific individuals or groups?Please give detailsIs there any more information that would be helpful for us to know?Please give details Parental ConsentI acknowledge that the staff will be liable in the event of any accident only if they have failed to take reasonable care of my child during the activity.Activities* I consent to my child taking part in the activitiesBehaviour* I have read the Code of Conduct expected during the activity and I undertake to reinforce this information with my childMedical* I agree that staff should take any medical action deemed necessary in the event of an emergency.Photography and filming I have read the Pro Corda Photographic Policy and give permission for photos to be taken and reproduced accordingly.Information* I give my consent to this information being shared with any organization that will be providing direct care for my child.We have a strict policy that only allows personal information to be used for limited purposes. We will never sell it or share it with another organisation for their benefit. Unless indicated below the personal information you provide will only be used and retained in relation to the course or courses applied for, and (if appropriate) to invite students to future courses. If at any time you wish to be taken off our contact lists please email us: mail@procorda.com.Keeping in touchPro Corda is a non-profit making registered charity that relies on support from students, parents and alumni as well as on grant funders and volunteers. We would like to be able to keep in touch with you periodically about our work, including our exciting development plans. We would like to be able to do this by email to reduce costs, but we need your agreement to that.Please keep in touch about: Concerts and events Our development initiatives and plans I am happy for you to contact me by email about these Consent*Please confirm that you give us permission to handle your information. Please review our Privacy Policy for more details. I agree to the privacy policy.
