Needs Form - Once Upon a Smile

Childs Name Seeking Support

Name Surname

Childs DOB*

Childs Gender

Childs School Name

School Telephone Number

Teacher's Name

School Year group

Parent/Guardian Name*

Name Surname

Address*

Street Address Address Line 2 City Post Code

Relationship to Child*

Telephone Number

Additional Emergency Contact Name

Name Surname

Emergency Telephone Number

Relationship to Child

Additional Emergency Contact Address

Adress Address Line 2 City Post Code

Childs GP*

Surname

GP Address*

Street Address Address Line 2 City Post Code

GP Telephone Number

Does Your Child Have a Disability that Once Upon a Smile Should Know About?*

Yes
No

If yes, please provide details of the disability including any help that your child may need.

Does your child suffer from any medical conditions?*

Yes
No

If yes, please provide details of the medical condition and any medication required.

Does your child have any allergies?*

Yes
No

If yes, please provide details of the type of allergy and medication.

Is there any other relevant information (eg: dietary requirements, childs fears, needs related to your childs age, development or circumstances) that you as parent/guardian would like to share?

Declaration*

I agree to the names above being kept on database for tracking and contact purposes. I agree that Once Upon a Smile can share information with other organisations working with myself and my child including education and health. I agree to my child attending Once Upon a Smile for an assessment. I agree to my child engaging with Once Upon a Smiles services.

Photograph & Video Declaration.*

At Once Upon a Smile, we love to share the amazing work our children take part in. This can include photographs and video with the possibility of sharing on our social media platforms.

Yes, I agree
No, I do not agree

Remote Support*

Our way of working is constantly changing and we have recently introduced remote support sessions. This can be sessions done via (but not limited to) ZOOM. Do you agree for your child to take part in remote sessions if we feel that is the best way to offer support at this time?

Yes, I agree
No, I do not agree

Date of Completion

GDPR*

By completing this form you agree to OUAS keeping this information stored on a secure electronic case recording system in accordance with GDPR. If you want to find more about how we use people’s information, you can access our privacy policy on our website. (here).