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Parent Carer Membership (1)
Parent/carer details
Full name
Full Address (house name/no, road, town)
Postcode
Telephone
Mobile
Email address
Tell us of your relationship to the child/young person with additional needs and/or disability
Please choose
Parent
Carer
Guardian
Foster parent
Grandparent
Child/young person with additional needs
Number of Children
1
2
3
4
5+
Child/young person's name (First)
Date of birth
School attending
Please could you describe the nature of any difficulties for your child/young person or diagnosis if this has been given?
Please tell us about anything you would like us to know about your child/young person or family?
List of additional Children
Child/young person's name (No2)
Date of birth (no2)
School attending (no2)
Please could you describe the nature of any difficulties for your child No2 / young person No 2 or diagnosis if this has been given?
Child/young person's name (No3)
Date of birth (no3)
School attending (no3)
Please could you describe the nature of any difficulties for your child No3 / young person No 3 or diagnosis if this has been given?
Become involved with SPCN
Please tell us about anything you would like us to know about your child/young person or family?
Please tick the box below if you would like to be involved with SPCN in any of the following ways:
Attending meetings with the local authority or health to put forward parent/carers views (training will be given if you need it).
Helping to organise social events for families e.g. refreshments, raffle, booking room, organising transport.
Fundraising for SPCN
Meeting other parents/carers in your area and helping them to get involved with SPCN
Please tell us how you heard about SPCN? from other parents?
Please choose one option that best describes your ethnic group or background?
White
Welsh/English/Scottish/Northern Irish/British
Irish
Gypsy or Irish Traveller
Any other White background, please describe
White / other, Please decribe
Mixed/Multiple ethnic groups
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed/Multiple ethnic background, please describe
Mixed/Multiple ethnic groups / Please decribe
Asian/Asian British
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background, please describe
Any other Asian background / Please decribe
Black/African/Caribbean/Black British
African
Caribbean
Any other Black/African/Caribbean background, please describe
Any other Black/African/Caribbean background / Please decribe
Other ethnic group
Arab
Any other ethnic group, please describe
Any other ethnic group, please describe
Phone
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: this reflects our experience. Disabled children & young adults are being treated shamefully.
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Suffolk Parent Carer Network - SPCN