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Child #1 First Name

Child #1 Surname

Age #1

Current School #1

Add 2nd Sibling?

Yes No

Child #2 First Name

Child #2 Surname

Age #2

Current School #2

Add 3rd Sibling?

Yes No

Child #3 First Name

Child #3 Surname

Age #3

Current School #3

Parent/Carer First Name

Parent/Carer Surname

Relationship to Student

First Line of Address

Postcode

Contact Number

Can This # Be Used in an Emergency?

Yes No

Emergency Number

Add Another Parent/Carer?

Yes No

Parent/Carer #2 First Name

Parent/Carer #2 Surname

First Line of Address #2

Postcode #2

Contact Number #2

Relationship #2 to Student

Does Your Child Have Any Diagnosed Conditions or EHCP?

Will Your Child Require Medication During The Sessions? If Yes, Please Specify

Does your Child Have Any Allergies?

Does Your Child Use Verbal Communication?

Does Your Child Use Alternative Communication? (Sign Language etc).

Does Your Child Have Any Sensory Needs?

Does Your Child Enjoy Interacting With Peers?

Are There Any Specific Behaviours That We would Need To Be Aware of?

Does Your Child Need Support With Daily Activates Such as Eating/Toileting etc

Is There Any Other Information You Feel Would Be Relevant?

I consent to the information enterd to be used to assess my child's compatability with ASD Stars

Yes No

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