Yellow Submarine | learning disability

Young Person First Name*
Young Person Last Name*
School/College*
Date of Birth*
DD slash MM slash YYYY
Religion*
(Please select)
Gender*
Language spoken at home*
Ethnicity*
(Please select)
What is typically the most convenient location for the young person when attending our activities*
Does the young person receive a personal budget?*
If no, funding may be available to help on arrangement
Do you consider yourself to be*
- a working family - Family in employment working at least 24 hours per week, with one parent/carer working at least 16 hours
- a single parent family, where the parent/carer is working at least 16 hours per week
- a 'Non-working' family or not meeting the requirements outlined above
(Definitions provided by Oxfordshire County Council)
Is childcare essential for work?*
- Yes
- No

Contact Person Details e.g. Parent/Carer
Contact Person's First Name*
Contact Person's Last Name*
Relationship to Young Person*
Home Telephone Number*
Mobile Number*
Email Address*
House number/name*
First line of your address*
Town*
Postcode*
Emergency Contact
Please list two people who can be contacted in an emergency; these should be different to the named contact person.
Emergency Contact 1: First Name*
Emergency Contact 1: Last Name*
Relationship to Young Person*
Home Telephone Number*
Mobile Number*
Emergency Contact 2: First Name*
Emergency Contact 2: Last Name*
Relationship to Young Person*
Home Telephone Number*
Mobile Number*

Potential Risks
Does the young person abscond from settings or people?*
- Yes
- No
If YES please give details, and explain how staff should manage the situation if it arises*
Can the young person be physically or verbally aggressive?*
- Yes
- No
If YES please give details, and explain how staff should manage the situation if it arises*
Does the young person self-harm or have a history of self-harm?*
- Yes
- No
If YES please give details, and explain how staff should manage the situation if it arises*
Please describe any other difficult/challenging behaviour the young person may experience*
Please list anything that causes the young person anxiety or fear, and how (s)he expresses being stressed or scared*

How to support the Young Person well
Is there any involvement from other professionals in the young person's or family's life?*
- Yes
- No
e.g. social worker; behavioral support workers; CAMHS
If YES please give details*
What things are important to the young person?*
(e.g. particular interests, people)
Are there any areas of the young person's development that you would specifically like our staff to support?*
If the young person is distressed what is the best way for staff to comfort them?*
Is there any additional information you would like us to be aware of?*
Declaration
I confirm that all of the above information is correct to the best of my knowledge and I understand that this data will be stored under the Data Protection Act 2018 and GDPR regulations. The information may be shared between relevant staff and authorities to ensure that the young person can be appropriately supported otherwise it will be treated confidentially. Full details of Yellow Submarine’s policies can be found here: https://www.yellowsubmarine.org.uk/policies/*

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