THIS CLUB IS NOW FULLY BOOKED

Spectrum Star Club details Spectrum Star Club detailsSpectrum Stars Club Worlds End AM Club

Please select the weeks you wish to book your child on to Please select the weeks you wish to book your child on to Week 1 Week 2 Week 3 All weeks

Email address

About your child

Child's last name

Child's first name

Home address (Where the child resides)

Gender GenderMaleFemale

Name of school

Does your child receive free school meals? Does your child receive free school meals?YesNo

Free school meals code (This can be obtained directly from your child's school)

Does your Child have a spectrum diagnosis? Does your Child have a spectrum diagnosis?YesNo

Is your child receiving SENCO support from their school? Is your child receiving SENCO support from their school?YesNo

Does your child have a EHCP (Educational Health and Care Plan) Does your child have a EHCP (Educational Health and Care Plan)YesNo

Date of birth (e.g._01/04/1980)

Please tell us about your child's needs. It is IMPORTANT that you are honest as we use this information to ensure we can support your child in the best way

Emergency Contact Details 1

Contact number

Emergency Contact Details

Special educational need/ Spectrum conditions (Please list)

Contact number 2

Relationship to child

Emergency Contact Details 2

Relationship to child 2

Disability

Additional information

Is your Child on medication? Is your Child on medication? Yes No

If yes, list medication and dosage to be taken

Ethnicity Ethnicity Asian/Asian British – Other Black/Asian/Caribbean/Black British African Black/Asian/Caribbean/Black British – Other Mixed/multiple ethnic groups White and Asian Mixed/multiple ethnic groups White and Black African Mixed/multiple ethnic groups White and Black Caribbean Mixed/multiple ethnic groups – Other White – Welsh/English/Scottish/Northern Irish/British White – Irish White – Gypsy, Roma or Irish Traveller White – Eastern European White – Other Other Ethnic group – Arab Any other Ethnic Group

Special educational needs

Behavioural information

Dietary requirements Dietary requirements No meat Vegetarian Diary free Egg free Wheat free Gluten free Halal Kosher Vegan No pork My child does not have a dietary requirement

Please tell us about any other dietry requirements

Bring it on Brum code:

Thank you for your application. If your child is successful in securing a space we will let you know via e-mail and or telephone

Tick boxes - all mandatory Tick boxes - all mandatory I consent to photos being taken of my child and used on the FTLOS Birmingham website (Spectrum Stars Mother company), social media plate forms and shared with School I consent to Spectrum Stars Club sharing and seeking information with my childs school for the purposes of enhancing my childs experience whilst at the club I give medical consent in the case of an emergency I agree to collecting my child/ children on time each day By providing my e-mail address I agree to subscription to the Spectrum Stars News Letter.