User Registration Child or young person's nameName* First Middle Last Any other name child has been known by Name Child or young person’s home address and contact detailsAddress* Street Address Address Line 2 Town Postal Code PhoneEmail EducationA child does not need to have a statement or an EHC Plan to be on the RegisterType of school that your child or young person attends*Early Years settingSpecial day schoolSpecial residential schoolResourced provisionMainstream schoolHome educatedIn employment or trainingIn further or higher educationNot in education, employment or trainingAssessment of your child’s educational needs*Education Health Care Plan (EHCP)Learning Difficulty Assessment (LDA)Early Help AssessmentChildren and Families AssessmentPupil Funding AgreementNone of the aboveChild's Personal DetailsDate of Birth* DD MM YYYY Gender*MaleFemaleNHS Number*If you're registered with a GP, you will already have an NHS Number. Your NHS number will be on any letter or document you have received from the NHS, such as prescriptions, test results, and appointment letters. Alternatively contact your GP practice and ask them to look it up for you.Carer DetailsName* First Last Address* Street Address Address Line 2 Town City Postal Code Carer Relationship*Birth parentAdoptive parentSpecial GuardianFoster carerKinship carerStep parentPhoneEmail What type of SEN and disabilities does your child experience?Needs* Specific learning difficulty Moderate learning difficulty Severe learning difficulty Profound & multiple learning difficulty Social, emotional and mental health Speech, language and communication needs Hearing impairment Visual impairment Multi-sensory impairment Physical disability Autistic spectrum disorder Other difficulty or disability SEN support but no specialist assessment of type of need Life limiting illness If you would like to expand on your child/young person's SEN or disability, please use this boxImpact of disability (Please tick any of the boxes that apply)* Balance and stability Consciousness Day to day care Emergency interventions Hand function Hyperactivity Incontinence Impulsiveness Mobility, function and posture Motor coordination Moving and handling Muscle tone Periods in hospital Personal care Poor coordination Requires palliative care Social relationships Speech, language and communication Medical diagnosis (Please tick any of the boxes that apply)* No formal diagnosis Awaiting diagnosis Attention deficit hyperactivity disorder (ADHD) Autism spectrum disorder Acquired brain injury Cerebral palsy Chronic fatigue Complex communication disorder Congenital brain malformation Congenital hypothyroidism Congenital hypertonia Congenital infection Congenital hip dislocation Congenital muscular dystrophy Cystic Fibrosis Developmental coordination disorder Downs syndrome Encopresis Epilepsy Foetal alcohol spectrum disorder Fragile X syndrome Genetic disorder Global developmental delay Hearing impairment Hydrocephalus Hypermobility syndrome Idiopathic toe walker Learning / intellectual difficulties Minor gait abnormalities Mitochondrial disease / disorder Motor delay Myotonic dystrophy Muscular dystrophy Neurodegenerative condition Neurofibromatosis Neurometabolic disorder Neuromuscular junction disorder (Myasthenia) Neuropathy Progressive intellectual and neurological deterioration (PIND) Restrictive eating disorder (ARFID) Skeletal dysplasia Spinal muscular atrophy (SMA) Sleep difficulties Speech and language delay Spina bifida Tic disorders Tuberous sclerosis Visual impairment William’s syndrome DiGeorge syndrome Chronic illness causing functional disability Other Please specifyServicesDoes your child use services from the any of these providers? (Please tick any of the boxes that apply) Adult social care Children’s social care Education Health Voluntary, Charity, Faith Sector Day time short break Overnight short break EquipmentDoes your child use any of the following types of equipment? (Please tick any of the boxes that apply) Communication Computing Eating and drinking Home adaptations (ramp / through floor lift / wet floor shower) Medical (suction / ventilator) Mobility (walking frame / wheelchair / specialist buggy) Personal care (toileting / bathing) Play, learning and development Postural care (static seating / sleep system) Transport (adapted vehicle) EthnicityPlease tick the box closest to child's ethnic backgroundAfricanCaribbeanAny other Black backgroundBangladeshiChineseIndianKashmiriPakistaniAny other Asian backgroundDo not wish to answerWhite BritishWhite IrishWhite and AsianWhite and Black AfricanWhite and Black CaribbeanAny other White backgroundTraveller of Irish heritageGypsy or TravellerAny other backgroundData Protection Act 1998In accordance with the Data Protection Act 1998, we are obliged to inform you that by signing this form you are giving your specific consent for Wirral Council to process the information we collect from you for the purpose of registering your details on Wirral’s Children’s Disability Register. In accordance with the Children Act 1989, we are required by law to have a register. The information collected may, where appropriate, be shared with other areas within Wirral Council, other relevant professionals and organisations, such as the NHS. Any sharing of information will be done only where it is necessary or where we are legally obliged to do so in strict accordance with the Data Protection Act. Your information may be collated or monitored, in an anonymised format, for the purposes of improving and shaping the services we offer in Wirral.Consent for Registration* I agree to my child's name being included on the Wirral Children's Disability Register.