User Registration

Child or young person's name
Name*
First Middle Last
Any other name child has been known by
Name
Child or young person’s home address and contact details
Address*
Street Address Address Line 2 Town Postal Code
Phone
Email
Education
A child does not need to have a statement or an EHC Plan to be on the Register
Type of school that your child or young person attends*
- Early Years setting
- Special day school
- Special residential school
- Resourced provision
- Mainstream school
- Home educated
- In employment or training
- In further or higher education
- Not in education, employment or training
Assessment of your child’s educational needs*
- Education Health Care Plan (EHCP)
- Learning Difficulty Assessment (LDA)
- Early Help Assessment
- Children and Families Assessment
- Pupil Funding Agreement
- None of the above
Child's Personal Details
Date of Birth*

DD
MM
YYYY
Gender*
- Male
- Female
NHS 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 Details
Name*
First Last
Address*
Street Address Address Line 2 Town City Postal Code
Carer Relationship*
- Birth parent
- Adoptive parent
- Special Guardian
- Foster carer
- Kinship carer
- Step parent
Phone
Email
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 box
Impact 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 specify
Services
Does 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
Equipment
Does 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)
Ethnicity
Please tick the box closest to child's ethnic background
- African
- Caribbean
- Any other Black background
- Bangladeshi
- Chinese
- Indian
- Kashmiri
- Pakistani
- Any other Asian background
- Do not wish to answer
- White British
- White Irish
- White and Asian
- White and Black African
- White and Black Caribbean
- Any other White background
- Traveller of Irish heritage
- Gypsy or Traveller
- Any other background
Data Protection Act 1998
In 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.

User Registration

Child or young person's name

Child or young person’s home address and contact details

Education

Child's Personal Details

Carer Details

What type of SEN and disabilities does your child experience?

Services

Equipment

Ethnicity

Data Protection Act 1998