Entry to School Holiday Programme (SHP) The parent or caregiver is to complete this form. The form is then to be stored in the eCase Gallery under Pre-Entry. Section 1: Personal details Your surname* Your first name* preferred name* Is client name different from legal name?* NoYes Date of birth* Your email* NHI* Ethnicity* Iwi/Hapu Is an interpreter required?* NoYes Details Section 2: Contacts A minimum of three contacts must be provided. Name* Relationship* Address* Phone* Email* Name* Relationship* Address* Phone* Email* Name* Relationship* Address* Phone* Email* Section 3: People authorised to collect child Names* Details of any person of concern Section 4: Disability Diagnosis/Condition* IntellectualIntellectual + PhysicalPrada WilliCerebral PalsyAutism/ASDDowns SyndromeIntellectual + Mental HealthAcquired Brain InjuryGlobal Developmental DelayOther - please specify Give a brief description of your child’s level of independence Mobility* WalksNeeds assistanceUses wheelchair to go outAlways uses wheelchair Hearing* No hearing lossUses a hearing aidNo hearing at all Vision* No problemsUses glassesPartial vision or no vision at all Seizures* No seizuresInfrequent mild seizuresMajor seizures infrequentlyMajor seizures frequently Understanding* Understands most things (even if it takes time)Understands simple words and phrasesLooks at things as they happen around them Communication* Able to talk with peopleUses a few words or short phrasesCommunicates by facial expression, gestures or sounds Ability to Evacuate in the event of a fire/emergency* Simple command is sufficientSome supervision/ assistance is requiredConstant supervision/ directions requiredNo understanding / must be physically assisted Support ratio needed for the child* Section 5 - Communication Supports or tools Sign languageiPad/tablet with communication appMakatonVisual aids (pictures/symbols) Comments Section 6 – Eating and drinking Dietary issues Section 7 - Toileting Wears nappies* NoYes Does your child need assistance to go to the toilet?* NoYes If needed, do you consent for your child to be changed by a staff member* NoYes Section 8 – Health Doctor's name* Doctor's phone* Doctor's address* Diagnosed conditions Allergies Immunisations Is medication required to be given?* NoYes If yes, please ensure the medication is brought to the program in original packaging with your child’s name, pharmacy labels, and instructions (must be accompanied by the Doctor’s signing chart). Also ensure you sign the medication register each day your child attends. I give permission for Spectrum Care to administer medications while my child is attending the School Holiday Programme* NoYes Section 9 – Individual or cultural preferences Food - Likes Food - dislikes Possession - Likes Possession - dislikes Routines and Activities - Likes Routines and Activities - dislikes Other Comments e.g. any anxiety or fears Section 10 – Risks and safeguards Anxiety or self-harm* No riskMildModerateSevere Description of risks and triggers Prevention and management of risk Harm to others* No riskMildModerateSevere Description of risks and triggers Prevention and management of risk Property damage* No riskMildModerateSevere Description of risks and triggers Prevention and management of risk Absconding* No riskMildModerateSevere Description of risks and triggers Prevention and management of risk Sexual behaviour* No riskMildModerateSevere Description of risks and triggers Prevention and management of risk Other No riskMildModerateSevere Description of risks and triggers Prevention and management of risk Section 10 – Agreement Spectrum Care will be responsible for: Providing regular short duration assistance to give a break to the primary caregiver of the person with a disability through the attendance at the School Holiday Programme, for days as specified by Spectrum Care. Communicating prior, during, and after School Holiday Programme. Ensuring that relevant information is passed on to the parent in a timely manner. Complying with Code of Conduct, and Health & Safety Policies to ensure the safety of child while attending School Holiday Programme. Providing access to first aid and following policies and procedures when administering medication. Staff will take responsibility in case of accident or injury. Employing staff that are trained to provide support to the child while attending the School Holiday Programme. Supporting each child to experience a safe and enjoyable Holiday Programme. The family/whanau of the person will be responsible for: Accepting the payment terms that have been outlined to them by the programme Service Coordinator. Communicating needs and informing the Programme Leader and staff of ongoing issues/changes regarding the person’s well-being and any changes in hours requested. Providing all relevant information to ensure optimum care of the child is provided to Spectrum Care in a timely manner. Transporting the child to and from the School Holiday Programme (unless otherwise arranged). Drop off no earlier than ......am and pick up no later than ......pm Supplying suitable contribution (e.g. $5.00) towards community outings (e.g. bus trips, swimming pool, fun parks). Meeting any unexpected costs /expenses incurred from emergency situations where the person may require treatment from a doctor. In such cases the account will be forwarded directly to the family. In instances where the child is ill, it is the responsibility of the parent/guardian to collect the child and take to the Doctor. If the child is unwell when due to attend the School Holiday Programme it is the responsibility of the parent/guardian to inform the staff. Supplying clothing adequate and appropriate for activities and personal toiletries. Spectrum Care supports individuals who require medication by ensuring that safety is maximised, any risks are addressed, and individuals receive the appropriate medication at the appropriate time. To achieve this, and comply with various laws etc, including the Health and Disability Standards, there are several requirements that must be met each time a child attends the School Holiday Programme: All medication must be prescribed by a GP or specialist (occasionally this will be a dentist) and the School Holiday Programme must have an up-to-date copy of the doctor’s signing sheet. All medication must be dispensed by a registered pharmacist. Therefore, medication coming to the School Holiday Programme must be in pharmacy labelled packaging. Staff cannot ‘choose’ to change the prescribed medication, e.g. withhold or increase, unless there is a documented plan for this situation e.g. an epilepsy crisis plan. Covering the cost of any property damage caused by the person. Neither the support worker, nor Spectrum Care will be liable. If your child’s behaviour is such that it detracts from the welfare of the other children, their place in the programme may be compromised. Parents are responsible for providing adequate meals (lunch and drink) that meet accepted principles of good nutrition and cater for the needs of the child. Parents agree that their child be transported in vehicles used by the Holiday Programme on outings. Section 11 – Any other information that needs to be shared Comments Section 12 - Authorisation of Agreement Name of person signing on behalf of the person receiving services* Date signed* Relationship to the person receiving services* Signature* Information on complaints or nagative feedback Information on privacy and personal information
