Categories
REACH Membership - 12 months
£20.00
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's 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 needs e.g. is your child on a special diet?
Enter your text
How does your child communicate his/her needs e.g. toilet, drink etc?
Enter your text
Does your child require support for any of the following; please give brief details if any of these apply: Physical Difficulties Emotional Needs Special Interests/Obsessions Phobias General Safety Behavioral 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 house hold? If so tell us there 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 permission for your child to have his/her photograph taken to promote the activities that are provided by REACH?
Enter your text
Do you give give permission for video footage to be taken of your child to promote the activities that are provided by REACH?
Enter your text
PARENTAL REQUEST FOR THE ADMINISTRATION OF MEDICINES AT REACH TO BE COMPLETED BY THE PARENT/GUARDIAN OF ANY CHILD REQUESTING DRUGS TO BE ADMINISTERED UNDER THE SUPERVISION OF REACH STAFF (If you need help to complete this form, please contact REACH Staff.) DOCTOR NAME, ADDRESS, PHONE NUMBER
Enter your text
PRESCRIBED MEDICINES Child's Name (If you have more than one child registered with REACH) Type Of Illness Name of First medicine Child's Name (If you have more than one child registered with REACH) Storage Inctructions Dosage Instructions Name of Second Medicine Child's Name (If you have more than one child registered with REACH) Storage Inctructions Dosage Instructions
Enter your text
I confirm that my child requires the above medicine(s) and that it/they can be administered by a non-medically qualified person. I will also undertake to inform REACH staff immediately of any changes in the medication and will provide an appropriately labelled separate supply. Yes No
Enter your text
Additional Info: This membership form will be retained by REACH and all information contained within it will 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 that 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?: * Facebook, Website, Email Advert, Other:
Enter your text
In stock
Product Details
Please complete each question on this form before submitting your membership request.
Save this product for later
REACH Membership - 12 months
You May Also Like
Display prices in:GBP
