Isle of Wight Council

Enrolment Form

Short Breaks funded by Aiming High Thompson House Sandy Lane Newport Isle of Wight PO30 3NA [email protected]

Child/young person's details

*	Forename
	Middle name/Initials
*	Surname

*

Date of birth

*	Building/house name/number
*	Street address
*	Town name
*	County
*	Postcode
*	Telephone number (include area code)

*	Sex	Male Female
*	Please state the primary need
	Please tick as applicable to your child	Autistic Spectrum Learning difficulties Physical Disability Complex health needs *Other
	*If 'other' please specifiy

Parent or carer's details

*	Title
*	Forename
	Middle name/Initials
*	Surname
	Address if different from the above
*	Telephone number
	Mobile telephone number
*	Email

*

How would you like us to contact you?

By email By post Not at all

	Ethnic Origin
	Please select the category that best fits your ethnic origin:
*	White British White Other White & Black African Other mixed group Pakistani Other Asian or Asian British Group Black African Other Black Group White Irish White & Black Caribbean White & Asian Indian Bangladeshi Black Caribbean Black & Asian Chinese

	Further information relating to your application
	Please complete the following questions if you wish to be considered for a short break funded by Aiming High for Disabled Children.

*	You are automatically eligible if you live on the Isle of Wight and are able to tick one or more of the following categories for your child: In receipt of Higher Level Disability Living Care Component Allowance Has a statement of Special Educational Needs Has undergone a professional assessment i.e. Common Assessment Framework, core assessment or professional diagnosis i.e. from a paediatrician or psychologist
	My child is receiving a service from one of the following: Children's Disability Team Portage Service/Early Support Team Occupational Therapy service Physiotherapy service Beaulieu House or Family Link Acute Nursing Team None of the above
	You are also eligible if you live on the Isle of Wight and are able to tick any two of the following for your child: Normal activities are interrupted by frequent health needs, affecting progress in development or education Requires frequent use of specialist equipment, including wheelchair/buggy and/or help from carer/parent to get around Requires regular support with basic self-care functions eg. eating, going to the toilet, washing, dressing and/or need more regular supervision during the day and sometimes at night than you would expect for a child of their age Does not hear spoken words and/or needs help to make up for complete loss of sound awareness and may have hearing aids or implants Has very little or no sight and/or are registered blind or needs support to move around

	Data Sharing
*	Your information will be held on a confidential database and will only be used to provide you with information and/or to enable you to use the services funded through Aiming High. You may also be eligible for any new short breaks provided in the future. If you are eligible, your information will be shared with the organisations supplying services for Aiming High for Disabled Children. Your information may also be shared with any new services that provide short breaks for the Isle of Wight Council in the future. Your information may also be used for statistical purposes to plan short break services to meet future demand and the needs of disabled children and young people.  I agree to the Isle of Wight Council keeping my details on a confidential database only for the purposes described above.

DECLARATION To the best of my knowledge, the details in this application are correct. Signed:...................................................   PRINT NAME............................................. Date:......................................................

	Data Protection Act 1998
	This application may be monitored by the Isle of Wight Council for regulatory, quality control or crime detection purposes. Information from this application will be processed in accordance with the Data Protection Act 1998 for the purpose of processing your particular enquiry/request. The Isle of Wight Council ("the Council") is the data controller. By completing this form you consent to the Council contacting you by email or nominated contact method in relation to your enquiry/request. The information contained in this application may, in exceptional circumstances, be subject to disclosure to third parties under either the Data Protection Act 1998 or the Freedom of Information Act 2000 to the extent the law allows and in accordance with the Isle of Wight Council's Access to Information Policy. Disclosure will only be made where in all the circumstances it would be fair to do so and in the public interest. Please note that the Council may process your information in the absence of consent for the purpose of crime prevention or detection so far as is in accordance with the law. Sometimes we may use your information to keep you informed about services, goods or relevant issues that we believe may be of interest to you. If you wish to receive this information for these purposes please tick this box To improve the quality of other services that we provide to you the Council wishes to hold your non-sensitive personal information on a secure central database. This will enable all Council services to use this information when they are providing a service to/for you. If you wish your non-sensitive personal information to be held by the Council please tick this box