Categories
REACH Membership - 12 Months
£0.00
Name
Enter your text
Address
Enter your text
Email
Enter your text
Phone Number
Enter your text
Today's Date
Please choose a date
Permission to use mobile number
Enter your text
Child Name
Enter your text
DOB
Please choose a date
Please give details of your child's diagnosis, if relevant. Please tell us if your child has Autism, ADHD, EDA, PDA, ARFID or any other diagnosis or awaiting referral:
Enter your text
Does your child have any dietary requirements?
Enter your text
How does you child communicate their needs such as toilet or drink?
Enter your text
Does your child require support for any of the following: please give a brief details if any of these apply: Physical difficulties, emotional neds, special interests/obsessions, phobias, general safety, behavioural difficulties
Enter your text
How do you support/deal with any of these challenges?
Enter your text
Any other conditions?
Enter your text
What school/nursery does your child attend?
Enter your text
Any other children in the household? If so tell us their name and if they have any other conditions
Enter your text
Emergency Contact Name
Enter your text
Emergency contact address
Enter your text
Emergency contact phone number
Enter your text
Do you give REACH permission for your child to have their photograph taken to promote activities that are provided by REACH?
Enter your text
Do you give REACH permission for video footage to be taken of your child to promote activities that provided by REACH
Enter your text
Doctor name, Address and phone number
Enter your text
Additional info: This membership form will be retained by REACH and all information contained within it shall be treated as private and confidential. REACH is a Scottish Charitable Incorporated Organisation, which means as a member you must 1)Act in the interests of the charity and 2) seek in good faith to ensure REACH act in a manner which is consistent with its charitable purposes. You will be asked to attend an AGM each year and can help make some important decisions about the charity. These decisions must be made carefully and with the best interests of REACH in mind
Enter your text
How did you hear about REACH Lanarkshire Autism
Enter your text
1x
In stock
Save this product for later
REACH Membership - 12 Months
