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:
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Any other Services or Professionals involved e.g. respite, OT, SaLTs?
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Is there any other relevant information?
e.g. safeguarding issues, cultural needs, risk to lone workers:
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GP Name & Address & Telephone No:
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Relevant Medical Information:
Please provide information about your diagnosis:
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Other Medical Conditions:
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Do you have any support plans or risk assessments in place? Yes ☐ No ☐
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More Information About You
How do you communicate? E.g. Makaton, communication books,
verbal speech, etc.
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Do you have difficulties with vision, hearing or speech? Yes ☐ No ☐
(If yes please give details and contact information for any support services)
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Do you have difficulties with eating/drinking? Yes ☐ No ☐
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Do you need any help with using the toilet or personal care? Yes ☐No ☐
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Do you have any mobility difficulties? Yes ☐ No ☐
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Do you have any allergies: Yes ☐ No ☐
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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:
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