Admissions Form

Futures Programme

Full and Part Time

 

Name: _______________________________

 

Name known by (optional): _____________________________________________

Address:__________________________________________________________

___________________________________Postcode: ______________________

Tel No: __________________________ D.O.B: ___________________________

 

Email: ____________________________

Date of application: ________________________

Year applied for: ___________________ Full Time ☐ Part Time ☐

Currently At (Please Name): ___________________________

School ☐ College ☐ Day Centre ☐ Other ☐

Please name other: __________________________________

Parent/Carer Name: _________________________________

Address (if different from above): _______________________________________

 ____________________________ Postcode_____________________________

Tel No: _______________________ Mobile No: ____________________________

 

Parent/Carer Name: _________________________________

Address (if different from above): _______________________________________

 

 ____________________________ Postcode_____________________________

 

Tel No: _______________________ Mobile No: ____________________________

 

 

 

Information About You 

Care Manager/Social Worker/Transition Team & Contact Details:

 ____________________________________________________________________ 

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

Any other Services or Professionals involved e.g. respite, OT, SaLTs?

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

Is there any other relevant information?

e.g. safeguarding issues, cultural needs, risk to lone workers:

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

 

GP Name & Address & Telephone No:

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

Relevant Medical Information:

Please provide information about your diagnosis:

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

Other Medical Conditions:

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

 

Do you have any support plans or risk assessments in place? Yes ☐ No ☐

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

 

More Information About You

How do you communicate? E.g. Makaton, communication books,

verbal speech, etc.

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

Do you have difficulties with vision, hearing or speech? Yes ☐ No ☐

(If yes please give details and contact information for any support services)

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

Do you have difficulties with eating/drinking? Yes ☐ No ☐

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

Do you need any help with using the toilet or personal care? Yes ☐No ☐

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

Do you have any mobility difficulties? Yes ☐ No ☐

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

Do you have any allergies: Yes ☐ No ☐

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

 ____________________________________________________________________

 

Even More Information About You

We would like to know more about you in order to support you and meet your goals & ambitions. We are interested in your likes and dislikes as they play an important role in creating your person centered plan.

Likes: 

 

 

 

 

 

 

Dislikes:

What do you hope Inclusive Pathways Community Learning Programme will help you to achieve?

 

Signed: _________________________ Date: _________________________

 

Last But Not Least

To speed up the application process please be sure to send us a completed

application form with all learner reports. If you have any question please call

or email us and we will do our best to get back to you as soon as possible.

 

School reports ☐

Annual Reviews ☐

Speech & Language ☐

Psychology or behaviour management ☐

Medical Information ☐

Risk Assessment/Support Plans ☐

Any other relevant information ☐

Please complete the following if supporting agency has completed form:

 

Name: __________________________________

Organisation: _____________________________

Position: ________________________________

Email: __________________________________

Phone: __________________________________

Signature: _______________________________

 

 

Send To: info@inclusivepathways.co.uk

 

 

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Address

Essex, UK

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