BOOKING FORM
Summer 2017
Thank you for applying for the
Big Splash Swim & Play Summer Scheme 2017
Please fill in and complete the questions below. Once we have received your form, we will
be in touch to confirm your place.
Name of child or young person with a disability:
Age :
Disability:
Address:
Postcode:
Borough:
School:
Contact Number:
E-Mail Address:
Name of Siblings Attending:
1.
Age
2.
3.
4.
Name of parent/carer attending:
Medical Information:
Please note that all medical and booking form information will be confidential and only seen
by the Hydrotherapy Pool management team.
It is important for parents/carers to bring along any emergency medication that is required.
Hydrotherapy staff are not able to administer medication.
Please tick any medical conditions that we will need to know about in order to meet the
young person or child’s needs:
Breathing
difficulties
Asthma
Chest
infections
Requires oxygen
Heart
problems
Existing
condition
Surgically
repaired
Stable
Blood
pressure
High
Low
Other
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Epilepsy
Well
controlled
Absence
seizure
Tonic/ tonic
clonic/
unclassified
seizures
Additional
tubing
Gastrostomy
button
Gastrostomy
peg
NG Tube
Tracheostomy
Hearing/
visual
difficulties
Grommets
Hearing
aids/device
Glasses
Registered
blind
Muscle tone
High
Low
Spasms
Dystonia
Skin
conditions
Eczema
Skin
infection
Chlorine allergy
Verrucae
Diabetes
Incontinence
Weight in
excess of 160kg
Swallowing
difficulties
Use of
thickeners
Others
Other
Care plan attached
Needs medication
after
minutes
Allergies
If any family members or person attending the Hydro Pool sessions have any medical
problems or health condition, please specify
Family member
Medical problem / Health condition
Mobility:
Walks unaided
Walks aided with one helper
Use of sticks/crutches
Walker/ frame
Wheelchair (electric)
Wheelchair independent user
Wheelchair dependant user
Hoisted, clips or loops sling? (C/L)
Chair entry (standing transfers only)
Use of disability bars
Use of changing/showering bed
Use of Shower chair
Swimming ability:
Beginner
Intermediate
Advanced
Independent
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Hydrotherapy Pool Session:
If you would like a Hydrotherapy slot please fill in the section below with your preferred
dates and times. Hourly session run throughout the day and are age related. Timings are
extremely important to enable the sessions to run efficiently.
You can book a maximum of three sessions along the Summer Scheme.


Children’s sessions: 9.00-10.00; 10.00-11.00; 11.00-12.00; 12.00-13.00
Young people’s sessions: 14.00-15.00; 15.00-16.00
Session
Preference
Example
Date
Time
Name and age of children and number of adults
attending in the water
11/8
9 - 10am 5 - Mum Jane, Dad Joe, Jessica 5, Jenny 15 and Jack 3
Choice 1
Choice 2
Choice 3
Workshops & Play sessions
A programme of play sessions runs throughout the Summer Scheme. If you would like to attend any of the
sessions please do tick the boxes, so we can make sure we have the right staffing levels.
 Morning Sessions run between 9am – 1pm. These sessions are for children aged 3 -11yrs
 Afternoon Sessions run between 2pm – 4pm. These sessions are for young people aged 12– 25yrs.
Please tick the play sessions that you would like to attend:
Morning session 9am – 1pm
3 – 11yrs
Week 1
Monday 31st
Arts: Dwali Festival
st
Tuesday 1
Special Yoga
11.00
12.00
Wednesday 2nd
Cooking: Indian Coconut Ladoo
Thursday 3rd
Sensory: Spices from India.
Friday 4th
Science Museum
Bubble show 11.00
Slime Show 12.00
Week 2
Monday 7th
Arts: Holi Festival
Tuesday 8th
Sensory story: Magic Carpet to India
th
Wednesday 9
Zoolab
12.00
Thursday 10th
Sensory: Indian Massage
Friday 11th
India Sports Day
Week 3
th
Monday 14
Arts: Flower Festival
Tuesday 15th
Blink Dance Theatre: Bollywood 12.00
Wednesday 16th Sensory: Gardening
Thursday 17th
Sensory: TAC PAC India
Friday 18th
Disco, Party & Smoothies
Afternoon Session 2pm – 4pm
12 -25yrs
Week 1
Arts: Dwali Festival
Special Yoga
14.00
Cooking: Indian Coconut Ladoo
Sensory: Spices from India.
Science Museum
Communication Show
14.00
Week 2
Arts: Holi Festival
Sensory story: Magic Carpet to India
Zoolab
14.00
Sensory: Indian Massage
India Sports Day
Week 3
Arts: Flower Festival
Blink Dance Theatre: Bollywood 14.00
Sensory: Gardening
Sensory: TAC PAC India
Disco, Party & Smoothies
Cancellations Policy
If you cannot attend for any reason to your hydro or workshop sessions, please let us know in advance. If
you fail to attend a session without notifying us, all of your future sessions might be cancelled.
Please give 24 hours’ notice for all cancellations and we will try and rearrange if possible.
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Consent Form:
I
(Parent/Carer) of
(Child/young person)
Consent for my child to participate in hydrotherapy/play
sessions.
Consent to first aid being administered by a trained first aider
whilst attending the Big Splash
Yes
No
Yes
No
Consent for pictures of my child taken in the hydrotherapy pool to be used
Signed:
On display boards.
Yes
No
On advertising material.
Yes
No
On The Big Splash Website.
Yes
No
On the Jack Tizard School Website.
Yes
No
Date
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Jack Tizard & Big Splash Trust
Hydrotherapy Pool Agreement
for Outside Community Use
For parents/carers supporting children and young people
In order for your child/young person to get the most from their sessions in the pool, we ask that you:
 Support the School’s policies and guidelines, especially for Manual Handling, Behaviour and Equal Opportunities.
 Ensure that your child attends all sessions booked. Telephone or email to inform us of any cancellations.
 Ensure that your child and all family members/carers are fit to attend sessions. No one should attend whilst
suffering from illness or ailments, e.g. Childhood diseases, chest infections, vomiting and/or diarrhoea.
(In the event of vomiting and/or diarrhoea, any individual will not be allowed to attend sessions until 48 hours from
the last symptoms).
 Ensure that everyone is appropriately dressed and properly equipped; (e.g. Nappies, towels, appropriate swim
wear, swimming nappies, Opsite covers for gastrostomies).
 Make the Hydrotherapy team aware of any concerns, problems or changes which may affect your child’s health,
behaviour or progress.
 Respect the staff and listen to their advice. Foul and abusive language or threatening behaviour towards Jack Tizard
Hydrotherapy Pool staff will not be tolerated.
 Provide the Hydrotherapy team with up to date contact details in case of illness or emergency (e.g. Change of
mobile, work or home phone numbers).
 Attend hospital promptly in the event of an emergency if required.
Children and young people will be encouraged to:
 Have fun and enjoy their sessions
 Respect and value themselves, other children/ young people, the staff and the environment.
The Hydrotherapy Pool Staff will:
 Provide a stimulating, fun and caring environment
 Encourage your child to achieve and make progress
 Provide a range of age-respectful resources and equipment to meet individual needs.
 Keep you informed of Big Splash activities and events.
 Keep you informed of any concerns regarding progress or behaviours.
 Provide a multi-disciplinary approach to learning.
 Liaise with other professionals (e.g. Social workers, educational psychologists, therapists and medical staff), when
required.
 Adhere to the Pool Safety Operating Procedures.
 Adhere to the Manual Handling Regulations, including procedures outlined in individual risk assessments.
 Retain the right to cancel sessions if a child fails to attend a pre booked session without notifying hydrotherapy
pool staff.
 Jack Tizard Hydrotherapy Pool staff have the right to refuse entry if the user is abusive or offensive in any way.
Together we will:
 Support the swimmers progress to help them to achieve their best.
 Provide a safe and enjoyable environment for all.
Signed
Signed
(Hydro Team)
Parent of
Date
Date
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