Warwickshire Parent Carer Voice Membership

You can become a Member of Warwickshire Parent Carer Voice if you have a child age 0-25 with any Special Educational Need or Disability (whether they have a diagnosis or not) and you live in or access services for your child in Warwickshire. We may send you details of events that we are organising, send you surveys or ask for your feedback on local services.

Membership is free and without obligation, we just ask that you share some basic information and details about how we can contact you.

Please do not complete this form if you are not a parent carer - if you are a professional or an organisation supporting families and want to receive our newsletter please email us warwickshireparentcarervoice@gmail.com to join our mailing list.

About You

First Name *

Last Name *

Gender *

Email Address *

Phone Number

District *

About Your Child / Young Person #1

Why do we ask this information?

Providing us with information about your child/children/young person will mean we can contact you about relevant issues.

Gender *

Year of Birth *

Child or Young Persons Needs/Disability (please select as many as appropriate) *

Type of Educational Setting your child/young person attends *

Does your child/young person currently have an EHCP? *

Yes

No

About Your Child / Young Person #2

Gender

Year of Birth

Child or Young Persons Needs/Disability (please select as many as appropriate)

Type of Educational Setting your child/young person attends

Does your child/young person currently have an EHCP?

Yes

No

About Your Child / Young Person #3

Gender

Year of Birth

Child or Young Persons Needs/Disability (please select as many as appropriate)

Type of Educational Setting your child/young person attends

Does your child/young person currently have an EHCP?

Yes

No

Siblings

My child/children detailed above have sibling(s) without needs or disability *

Yes

No

Your Thoughts

Please share with us what is working well for your family, what is not working well and what improvements you would love to see in respect of Education, Health and Social Care. If you would like to tell us more please feel free to email us at warwickshireparentcarervoice@gmail.com

What is working well for your family? *

What is not working well for your family? *

What improvements do you think would help your family? *

Equality and Diversity

Why do we ask this information?

The following information will help us to ensure that we are representing the full range of parent carers

Your ethnic background: please tick one box *

Are you a parent carer with a disability? *

Yes

No

Prefer not to say

Is your child entitled to free school meals? *

Yes

No

Prefer not to say

Are you a lone parent to the child/ young person with additional needs? *

Yes

No

Prefer not to say

Membership & Privacy

I am happy for my data information to be used anonymously for surveys/research projects and funding bids undertaken by Warwickshire Parent Carer Voice (WPCV) *

-

I understand that WPCV will store my membership data until the September following my son/daughter’s 25th birthday, or such time as I request they delete my membership details and terminate my membership. *

-

Are you interested in becoming more involved with WPCV by joining our Parent Representative Panel or joining our Steering Group (we can contact you to provide further information) *

Yes please, I would like to find out more

No thank you

Attention Deficit Hyperactivity Disorder (ADHD)	Autistic Spectrum Condition (ASC)
Blood Disorder	Brain Injury
Chronic Fatigue Syndrome / ME	Chronic Neurological Condition
Cystic Fibrosis	Downs Syndrome
Dyslexia/Dyspraxia/Dyscalculia	Emotional behavioural difficulties (EBD)
Global development delay	Hearing impairment
Medical needs	Mental Health Conditions
Moderate learning difficulties (MLD)	Profound and multiple learning difficulties (PMLD)
Physical disability	Sensory Processing Disorder
Severe learning difficulties (SLD)	Speech & language impairment
Spina Bifida	Unknown / Awaiting Diagnosis
Visual impairment	Wheelchair user
Other Other

Attention Deficit Hyperactivity Disorder (ADHD)	Autistic Spectrum Condition (ASC)
Blood Disorder	Brain Injury
Chronic Fatigue Syndrome / ME	Chronic Neurological Condition
Cystic Fibrosis	Downs Syndrome
Dyslexia/Dyspraxia/Dyscalculia	Emotional behavioural difficulties (EBD)
Global development delay	Hearing impairment
Medical needs	Mental Health Conditions
Moderate learning difficulties (MLD)	Profound and multiple learning difficulties (PMLD)
Physical disability	Sensory Processing Disorder
Severe learning difficulties (SLD)	Speech & language impairment
Spina Bifida	Unknown / Awaiting Diagnosis
Visual impairment	Wheelchair user
Other Other

Attention Deficit Hyperactivity Disorder (ADHD)	Autistic Spectrum Condition (ASC)
Blood Disorder	Brain Injury
Chronic Fatigue Syndrome / ME	Chronic Neurological Condition
Cystic Fibrosis	Downs Syndrome
Dyslexia/Dyspraxia/Dyscalculia	Emotional behavioural difficulties (EBD)
Global development delay	Hearing impairment
Medical needs	Mental Health Conditions
Moderate learning difficulties (MLD)	Profound and multiple learning difficulties (PMLD)
Physical disability	Sensory Processing Disorder
Severe learning difficulties (SLD)	Speech & language impairment
Spina Bifida	Unknown / Awaiting Diagnosis
Visual impairment	Wheelchair user
Other Other