Membership

Date of Birth *

Are you this child or young person's:
---ParentFamily member with caring responsibilitiesOther unpaid carerI'm a young person representing myself

Does this Child or Young Person have any Additional Needs? *
---NoneYoung CarerADHDAutistic Spectrum ConditionDown SyndromeHearing ImpairmentModerate Learning DifficultyMulti-Sensory ImpairmentPhysical DisabilityProfound and Multiple Learning DifficultySevere Learning DifficultySocial, Emotional or Mental Health DifficultiesSpecific Learning Difficulty (e.g. Dyslexia)Speech, Language and Communication NeedsVisual ImpairmentOther

Additional Areas of NeedADHDAutistic Spectrum ConditionDown SyndromeHearing ImpairmentModerate Learning DifficultyMulti-Sensory ImpairmentPhysical disabilityProfound and Multiple Learning DifficultySevere Learning DifficultySocial, Emotional or Mental Health DifficultiesSpecific Learning Difficulty (e.g. Dyslexia)Speech, Language and Communication NeedsVisual ImpairmentOther

Type of Setting (Nursery, School, College) Your Child Attends*
---MainstreamSpecialSRP (Specialist Resource Provision)Home educatedNot currently in education

Does this child or young person have:

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