PSC Parent/Carers' Registration Form

Parent/Carer Information

Your Surname*

Your First Name*

Your Title

Your Gender*

Your Post Code*

Address line 1*

Address line 2

Address line 3

Address line 4 (Town)*

Address line 5 (County)

Email Address (Main)*

Main Telephone No.*

Mobile Telephone No.

How would you like to be contacted?*

Which local council/Local Authority area do you live in?*

Which GP surgery are you registered with?*

What is your Parenting/Caring Role*

If 'Other' Parent/Carer Type, please state here

Do you have a medical condition that we may need to know about?*

How many children live with you?

What is your preferred language?*

Please provide the name of a family member or friend that we could contact in an emergency

Please provide the telephone number for your emergency contact here

How did you hear about PSC?*

Child/Young Person Information

Please only complete details for the child or children that you are seeking help for.

Child's Surname*

Child's First Name*

Child's Date of Birth*

Child's Gender*

Postcode*

Does your child have a diagnosed disability, or are they waiting for an assessment? * Please select.*

Does your child have any additional disabilities?

Additional Disabilities

Does your child have a medical condition?*

Which professionals are currently supporting your child? e.g. Speech and Language Therapist*

Which school or nursery does your child attend?*

Please give a brief summary of your child's current difficulties and/or reason for registering with our charity*

Additional Child/Young Person

Child's First Name

Child's Surname

Child's Date of Birth

Child's Gender

Postcode

Does your child have a diagnosed disability, or are they waiting for an assessment? * Please select.

Does your child have any additional disabilities?

Additional Disabilities

Does your child have a medical condition?

Which professionals are currently supporting your child? e.g. Speech and Language Therapist

Which school or nursery does your child attend?

Please give a brief summary of your child's current difficulties and/or reason for registering with our charity*

Additional Child/Young Person 2

Child's Surname

Child's First Name

Child's Date of Birth

Child's Gender

Postcode

Does your child have a medical condition?

Does your child have a diagnosed disability, or are they waiting for an assessment? * Please select.

Does your child have any additional disabilities?

Additional Disabilities

Which professionals are currently supporting your child? e.g. Speech and Language Therapist

Which school or nursery does your child attend?

Please give a brief summary of your child's current difficulties and/or reason for registering with our charity

For Monitoring Purposes Only

Choose one option that best describes your ethnic group or background (for monitoring purposes only)

Marital Status

Employed?

Consent Statement

Please select whether you give consent for Parenting Special Children to store sensitive personal information about you and your children.*