BOOK BELOW THIS CLUB IS NOW FULLY BOOKED Please confirm the club you wish to apply for by reselecting from the drop down below 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. 4 + 5 = Submit