Family Information

1. Child or young person's name *

2. Child or young person's date of birth *

	DD/MM/YYYY

3. Child or young person's gender *

Male
Female
Other/ prefer not to say

4. Main language

5. Child/young person's address and postcode

6. Contact details

Mobile phone
Home/other phone
Email address

7. Parent or carer 1 *

Name	*
Relationship to child/young person
Address (If different to above)
Phone number (if different to above)
Email (if different to above)

8. Parent or carer 2 *

Name	*
Relationship to child/young person
Address (If different to above)
Phone number (if different to above)
Email (if different to above)

9. Do we have consent to contact you by: *

Phone
Email
Post

10. Please briefly tell us about your child's condition or diagnosis (for example 'Down syndrome, heart condition, feeding issues').

11. Are there any health conditions or other issues that are relevant for us to know about for organising and running activities and trips? *

Yes
No

If yes, please give details

12. Does your child/young person have any allergies? *

Yes
No

If yes, please give details:

13. Sunshine and Smiles is dedicated to providing the support that is needed by the families we meet. Do you have any feedback on the support we provide or is there anything you would particularly like to see as part of our groups and family support?

14. We often take photos or video/audio recording at both our online and face to face groups, or collect written feedback. We would like to ask consent for this material to be used by Sunshine and Smiles- Leeds Down Syndrome Network as well as partner organisations (such as session providers or funding organisations). We would also like permission for any photos, videos or quotes that you yourself provide to us to be used in the same way. More information on this can be found here .

Do you agree and give permission for Sunshine and Smiles- Leeds Down Syndrome Network to use photos, footage and quotes as outlined above? *

Yes
No

15. Do you agree and give permission for Sunshine and Smiles- Leeds Down Syndrome Network to hold relevant and necessary personal information in accordance with our privacy policy? *

Yes
No

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