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Parent/Carer Information
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?*
Do you have a medical condition that we may need to know about?*
Child/Young Person Information
Please only complete details for the child or children that you are seeking help for.
Postcode*
Does your child have any additional disabilities?
Additional Disabilities
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 Surname
Postcode
Additional Child/Young Person 2
Please give a brief summary of your child's current difficulties and/or reason for registering with our charity
For Monitoring Purposes Only
Consent Statement
Please select whether you give consent for Parenting Special Children to store sensitive personal information about you and your children.*