Short Breaks Referral Form
Important Information and notice
Please read and complete all areas of this registration form
Each child must have a completed Short Breaks referral form before they can access any SNAP clubs.
 The information you provide will be used to create a passport record that will be available at each short
breaks setting your child may attend in the future
 SNAP will regularly ask you to check and update this information. Please also let us know if any
information changes so that we are able to keep in contact with you.
 The assessment of need will help SNAP to advise on the most appropriate services and support your child
to achieve towards individual targets and goals
Information sharing policy is adopted for all Bexley Council funded services
A condition of the funding is that we share information regarding families accessing our services. By becoming a
member of SNAP and/or accepting a place on any service, you are giving us permission to share this
information. If you DO NOT consent to share this information, we regret that your family will not be able to
access a Bexley Council funded service.
Please Complete all Passport Information
Child Surname
Child First Name
Family Surname
(if different)
Child Ethnicity
Date of Birth
School
Gender
Name:
Parent or Carer
(Please state)
First Name
Telephone
Email
Alternative Emergency Contact Name
Alternative Emergency Contact Number
Male / Female
Daily or Residential
Title
Mr / Mrs/ Ms / Miss
Mr & Mrs
Surname
Mobile
Bexley SNAP - Continued passport information and assessment of need
I am a looked after child or have needs and risks
subject to a Safeguarding plan, risk assessment
Please state yes or no
If yes we will contact you and may need to contact your Social Worker Name:
social worker/ school to support this information
Contact Number:
I am registered with the Disabled Children’s Service
Please state yes or no
If yes we will contact you and may need to contact your Social Worker Name:
social worker/ school to support this information
Contact Number:
I have a statement of Special Educational Needs or Please state yes or no
Education, Health and Care plan
Number of recommended hours
I receive a personal budget or Direct Payments from Please state yes or no
London Borough of Bexley
I like to be called (please use other names by which
your child likes to be called)
My diagnosis is (please list all)
I communicate by (e.g. verbal, PECS / symbols
My mobility is (include if your child is able to swim)
I have Medical needs (including tube feeding)
Please state yes or no
Please indicate if your child needs regular medication
and for what –
you will need to complete a ‘green’ Medication
Consent Form if they require medication whilst
attending a leisure scheme.
All medications must be in their original packaging with
the child/young person’s name clearly marked on
them.
I have Personal Care needs
Please state yes or no
Please indicate if your child needs regular support with
personal care and to what level –
You will need to provide appropriate changes of
clothes, nappies, pads, wipes. Without these items you Please give consent for the delivery of personal care
may be contact to collect your child if we cannot meet
their personal care needs
Sign:
Bexley SNAP - Continued passport information and assessment of need
This means I may do (please indicate particular
behaviours of your child)
When I do this, it means I am anxious (please indicate
signs your child displays when getting anxious or
distressed)
When I do this, it means I am happy (please indicate
behaviour displayed)
I like to (please indicate activities your child/young
person likes to do)
I do not like to (please indicate activities your
child/young person does not like to do)
I like to be calmed by (please indicate how we can calm
your child if distressed or angry)
I like to eat/drink (please indicate which food/drink)
I do not like / I cannot have to eat/drink (please
indicate which food /drink)
I am allergic to (Please include food allergies)
Other things you should know about me
GPs Contact Details (GP Address and contact number
to be used in an emergency)
Hospital Consultant (Name of Hospital and contact
number to be used in an emergency)
Bexley SNAP - Continued passport information and assessment of need
Please tick  to give your consent or cross X to note that you do not consent
Permission for outings
Take photos / video for
Take a photo to add to
with SNAP
external/publicity website
completed passport
local parks, shops
flyers, advertising and
facilities, community
presentations
Emergency escort in
ambulance
Apply sun cream as
required
Give Emergency 1st Aid
I am able to
swim
happy to get in a
swimming pool
All parents / carers must agree to SNAP’s behaviour policy
We focus on preventing situations of negative behaviour and risk to individual’s or others (Children, staff,
volunteers, visitors and parents/ carers) through
 Assessment and review of need
 Risk assessment
 Recording and reviewing Accidents/ Incidents and Safeguarding
 Shared communication - Parents/ carers regally informing leisure team of changes to need/ behaviour
 Appropriate planning and preparation
 Information sharing agreement with London Borough of Bexley, partners and professionals
In the event that we feel your child is a risk or danger to themselves or others we may remove them from a
situation/ environment. In the event that we cannot keep the rest of the children we are caring for safe you will
be contacted to collect your child from the scheme immediately.
Please provide your consent and agreement to the behaviour policy. If you have any questions or concerns please
speak to Claire Sullivan, claire@bexleysnap.org.uk
I confirm that the information I have provided is accurate and understand that it is my responsibility to notify
Bexley SNAP as soon as possible of any changes to the information contained herein.
Child Name:
DOB
Parent/ Carer Signed:
Date:
This Registration and Assessment has been checked by a member of the SNAP team
SNAP Signed:
Date:
Bexley SNAP – Services, Signposting and Goal setting
Please complete this section in full. Along with the registration information you have provided this will
 Support SNAP to gain an understanding of your child’s need and work with you and your child to set
individual goals and review achievements.
 Advise you and your child of appropriate SNAP leisure schemes and short breaks
 Signpost you to a catalogue of other available specialist or mainstream services
Child Name:
DOB:
SNAP/ other services I currently attend ( that apply):
Specialist
Mainstream
 MCCH
 Bexley Youth Services
 Moorings
 Parkwood Leisure swimming lessons or sports
 Charlton Ability Counts Programme
sessions
 Parkwood Leisure targeted disability swimming
 Charlton
lessons or sports sessions
 Other: ………………………………………………………..
 Falcon Spartak gymnastics club
…………………………………………………………………..
 Beavers disability swim session
…………………………………………………………………..
 Bexley NAS
 Other : ………………………………………………………………
Leisure Services I would like to access ( that apply):
 Saturday Fun Club - LBB
 Youth Club - LBB
 Buddy Club - LBB
 Archway Mechanics scheme
 Hydrotherapy sessions
Financial Support
I receive a personal Budget from LBB




Half Term Holiday Schemes - LBB
Easter and Summer Holiday Schemes - LBB
Made to Measure (Alternative funding)
Service you would like to see:
………………………………………………………………….
I receive Disability Living Allowance
Please include current needs and three positive things your child will work towards achieving whilst attending
SNAP leisure services. The leisure team will work to support progress towards individual and group
achievements, review and set new goals.
Why I need or want to access SNAP services:
Positive things I want to achieve as a result of
attending:
Any other information (referred services):
Signed:
Date: