*Disclosure:  We are aware that we may be asking some personal questions within this form. This is for data collection purposes only and would really help us towards reaching harder-to-reach voices and minority groups, to ensure they have a say. However, the questions are optional, so if you do not feel comfortable answering some of them, that’s absolutely fine!
 
By signing this form you are agreeing for SENDAC to contact you by email and occasionally post and to store your data in line with it's Data protection Policy. 
SECTION 1: parent/carer details 

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* 1. First and Last Name:

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* 2. Email address:

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* 3. District

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* 4. Address:
(Please Include postcode)

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* 5. Ethnicity:
(Optional*)

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* 6. Do you have any additional needs/disabilities yourself?
(Optional*) 

Please tick yes, if you are not diagnosed but believe you do have an additional need and/or disability 

SECTION 2: Child/Young Person's details
(if more than one child with an additional need/disability please answer about all children/young people) 

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* 7. Area of child/children's needs:
please tick all that apply

(No diagnosis needed)

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* 8. Gender : 
(optional*) 

if more than one child/young person please select all that apply

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* 9. Child(s) Date of birth: 
please write this in the following format DD/MM/YYYY

(if more than one child/young person please bullet point) 

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* 10. If you do not already have one, would you like us to send out a FREE MAX card for your child/young person? 

About MAX card: 

The Max Card is the UK’s leading discount card for families of children with additional needs and foster Families. Families can use their Max card at multiple venues across the UK to get free or discounted admission!
 The scheme is designed to help families save money on great days out at castles, zoos, bowling alleys, trampoline parks, museums and so much more!

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* 11. Do you consent for SENDAC to contact you via email in the future by adding you to our mailing list, where we will email you things such as free SEND training and free send events we are hosting exclusive to our members, changes and improvements made to SEND services etc?

(Don't worry we promise not to bombard you with emails!)

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