Office Use Only
Application for Coach Trip to Drusillas Park
Friday 2 November 2012
9am – 4pm, meeting at Oakley Secondary School
To fill this in on your computer, click on the grey fields and enter the information needed.
This application must be received before the deadline on Wednesday 17 October 2012.
Child’s forename: Child’s surname:
Child’s date of birth: Parent’s name:
Home telephone number: Mobile number:
Do you check this
Child’s ethnicity: School\College attended:
* - Contacting you at an e-mail address you guarantee to check regularly will help Barnardo’s keep administrative costs low.
Thank you for applying to join the trip to Drusillas Park on Friday 2 November 2012. The cost of this
event is £15. Please include a cheque payable to Barnardo’s with your application. If you do not receive
a place, this will be refunded. We may be in a position to offer concessions or other assistance to families who find it
challenging to meet the cost, or to travel to pick-up points. We welcome you to call and discuss what we can do to help.
Please briefly describe your child’s disability, impairment or needs.
Please provide details of any adaptations that may be required to allow your child to access this service, e.g. wheelchair
accessible transport. If you wish to discuss anything further you can contact us in confidence.
As your child is attending a service where we provide care, we need an up to date care plan. If we
(Holiday Activities, Barnardo’s, Kent Friendz, VSU, Kent Integrated Youth Services or Little Forest) already
have a care plan we can use that with your permission, as long as your child’s needs have not changed.
Do we already have a care plan that you want us to use? Yes No
Was/is this care plan … filled out by a parent. filled out with a member of staff.
Or … Please use my child’s care plan from this organisation:
Please note that we reserve the right to arrange for a new care plan if we feel it is necessary.
If we need to complete a new care plan we will be in touch to arrange this.
Does your son or daughter require constant one-to-one supervision? Yes No
If so, state why:
Please tell us how much of the following your son or daughter accesses per year. Please include all
services, specialist or mainstream, regardless of how they are paid for.
Only Use One Box
hours per hours per hours per Term time
Activity week month year or holidays?
School clubs (e.g. breakfast club, art club)
Evening clubs (e.g. Scouts, drama)
Music lessons / orchestras, etc
Sports clubs / lessons, etc
Holiday clubs / playschemes
Office use only T:
May we have your permission to contact you directly about future
short breaks via…
You confirm that the information you have given is true, If necessary, you agree to arrange to meet a member of
complete and accurate to the best of your knowledge. staff in advance of the service, either at your home or on
If there are more applicants than available places, the property of a consortium member, so we can complete
Barnardo’s will offer places based on the stated criteria. All a care plan.
decisions will be at Barnardo’s sole discretion. Your signature on the care plan will constitute further
Personal data will be processed in accordance with the Data consent, the details of which will be available at the time.
Protection Act 1988 and Barnardo’s policies & procedures. You understand that Barnardo’s will store information
Anonymous statistical data may be used by Barnardo’s or about you and your family both on paper and
other organisations to inform and monitor provision. electronically, and that you can ask to see this information.
If required, personal data may be passed on to other This information may be shared with Kent County Council
bodies for the prevention and detection of crime, including and other oversight bodies to report on activities.
fraud and child safeguarding matters. Information will also be shared with other consortium
You have a right to complain about any aspect of service. members.
Please tick this box to declare that the named parent agrees to the above.
If returning this form electronically this box is used as well as your name in the box below to
indicate you firmly agree to the above terms and conditions.
Name of parent: (required)
Name of child \ young person: (if appropriate)
Thank you for completing this form. Please return to firstname.lastname@example.org or
Barnardo’s Local Offer, Sunrise Children’s Centre, London Road, Southborough, TN4 0RJ