Parent/Guardian Name *

First Name

Last Name

Phone

(###)

###

####

Child's Name *

First Name

Last Name

Does your child have a formal diagnosis?

Medical and Support Needs

Yes

No

Assistance required with personal care (e.g. toileting, eating)?

Yes

No

Activities your child enjoys (select all that apply):

Outdoor play

Nature walks

Water play

Arts and creative play

Calm and sensory zone

Sensory and messy play

Ball games

Group games / Team activities

Music or dance

Life skills (e.g sandwich making, juice pouring, independent living etc)

Level of support required:

We will assess this together so it’s absolutely fine if you’re unsure at this stage

1:1

2:1

My child is generally okay in small groups (4-6 children)

Unsure

Which session would you be interested in? *

Extended Session (10am - 1pm)

Standard Session (11am - 1pm)