SHORT BREAKS CORE OFFER
APPLICATION
Automatic Referral to the KEY Hackney’s Register of children & young
people 0-19 with Special Educational Needs, Disabilities
• Write clearly and in block capitals
• Tick or circle the appropriate boxes when necessary
Part One: Details of Child or Young Person
First Name: ------------------------------------------------------------- Last Name: ---------------------------------------------------------Full Address : ----------------------------------------------------------------------------------------------------------------------------------------
Male ☐
Female ☐ Date of Birth (DD/MM/YY) ----------------------------------------------
Name of School/Play -Group/nursery/College
Age: --------------------------
--------------------------------------------------------------------------------------------
Does your Child have : EHCP ☐ SEN ☐ Complex Health Needs ☐ (please tick)
Carer contact details- Tel: ------------------------------------------------- Mobile: -------------------------------------------------------Email Address: ---------------------------------------------------------------How did you hear about Short Breaks? ------------------------------------------------------------------------------------------------------
Part Two:
how
Type of Diagnosed Disability
(Please write a number in the boxes that applies, to show
each difficulty affects young person. In each box write 1= mild or 2=moderate or 3=severe or 4=profound)
Please ensure to add the date of your child’s diagnosis here; ------------------------------1. Complex health needs ☐ 2. Learning disability ☐
3. Autistic Spectrum Disorder ☐ 4. Visual Impairment
☐
5. Medical needs ☐
9. Physical impairment
6. Mental health condition ☐
7. Speech & Language
☐ 10. Behavioural & Emotional Difficulties ☐
12. Syndrome/Chromosome Disorder ☐
☐
8. Hearing impairment ☐
11. Global/Development Delay ☐
Please add additional details of disability in the box below:
Please continue overleaf
Part Three : What is your ethnic group?
Please choose one section from the alphabetical list (A to E) below and tick the box you feel best reflects
your household’s cultural background.
A - Asian or Asian British:
Bangladeshi
☐
Indian
☐
Pakistani ☐
Chinese ☐
Vietnamese
☐
B - Black or Black British:
African
☐
Caribbean ☐
☐
Turkish
Nigerian ☐
Somali
☐
West African
Other
☐
Cypriot
☐ C - European:
Cypriot-Greek
☐
Kurdish
☐
Turkish ☐ D - Mixed Race:
Asian & White
☐
Black African & White
☐
☐
Black
Caribbean & White Other ☐
E - White or White British:
British Irish
☐
European
☐
Scottish
☐
Welsh
Eastern European
☐
☐
Jewish
Polish
☐
☐
Other
☐
Part Four: Child’s Special Needs
Part A: The KEY, Hackney’s Local Authority Disability Register (opt out)
By completing this form you will be added to Hackney’s Disability Register. Please tick here ☐ if you do not want to
join the Key (For more information on the Key and benefits of joining, please read attached document)
Is your child or young person in receipt of DLA or PIP at middle or high rate? Yes ☐ No ☐ if no, please skip to
Part B
Have you tried to access activities in a universal setting, Yes ☐ No ☐ which one? -------------------------------------
Children/young people who receive the short breaks offer are entitled to allocated hours at services where 1
adult supervises 4 children at the same time (1:4).
If you feel your child requires closer adult supervision then please tick here ☐
If you ticked yes, we will need to carry out a light touch assessment of your child at the setting of your choice before
we can agree to fund a 1:1 staffing ratio. This involves a risk assessment carried out at the setting by the provider
and an observation carried out by the Short Breaks Health Integration Team (HIT Squad). If you agree
for the above process to be carried out please tick here ☐
Part B: Signature of parent/carer/young person (minimum age 16) -----------------------------------------------------------Print name ------------------------------------------------------------------------ Date ------------------------------------------------------
Please continue overleaf
Part Five: What we need from you
If you are not in receipt of DLA at middle or high rate and are joining the Key, please provide a supporting
statement or proof of
your child’s disability. This can be a low rate DLA letter, SEN Statement, letter from
an Ark professional or other therapist.
If you have not yet applied for Disability Living Allowance, please do so before applying for short breaks
funding (you can get support completing your Disability Living Allowance form by Hackney Carers centre 0208
533 0951)
……………………………………………………………………………………………………………………………......
If you are in receipt of middle or high rate DLA, p
lease provide us with an up to date and original
Disability Living Allowance / PIP document showing that you are in receipt of a care component at middle or
high rate.
If your child or young person is not currently in receipt of Disability Living Allowance, due to the following;
Disability Living Allowance is currently being processed
• No recourse to public funds
• You were referred by a social worker
A professional may submit a supporting letter on your behalf and your application will be considered on a case
by case basis. Please also provide proof of address in the form of a utilit
y bill or bank statement.
Please note: We will return all documents back to you.
By ticking this box you agree to us contacting internal agencies and sharing information with providers and
other internal health professionals
☐
Part Six: Completed application form;
Please post your completed application form with supporting documents to:
Short Breaks Team,
2nd Floor Hackney Learning Trust Technology & Learning Centre (TLC),
1 Reading Lane
London
E8 1GQ
For more information on short breaks, please visit our website
www.shortbreakshackney.com
Please continue overleaf