In Touch
Want to receive regular information on services for disabled children and
young people?
If you have a disabled child aged 0-25 years old, live in Camden and want to be sent regular information
about short breaks, activities, support groups, events etc that may be of interest to your child or family then
sign up to In Touch.
Please provide us with details about your family so we can send you relevant information.
Child’s Details – please provide information on your disabled children only
CHILD 1
CHILD 2
Surname/ Family
name:
First name (s):
Date of Birth:
/
/
/
/
CHILD 3
/
/
Gender:
Ethnicity:
Nursery/ School /
College:
Does your child have a diagnosis and/or syndrome that describes his/her disability? (Tick all that apply)
Challenging
Behaviour
Learning
Disability
Physical
Disability
Wheelchair
User
Hearing
Impairment
Visual
Impairment
Communication
Difficulties
Is your child in receipt of high rate DLA? (Tick all that apply)
Mobility:
Personal Care:
Disability Card:
If your child (0-18yrs) has a permanent and substantial disability they may be eligible for a Camden
disability card which can help to gain discounts at various settings. To receive a card you will need to
agree for Camden Council to contact your NHS trust to seek relevant information about your child’s
disability. If eligible, a member of our team will contact you to arrange photos for the card.
Please tick below to confirm for each child “I would like my child to be considered for a Camden Disability
Card and agree for my NHS trust to be contacted”.
Note: You do not need to reapply if you already have a disability card.
Tick all that
apply:
Do you have any children under 18 who are not disabled?
Yes /
No
(please circle)
Families Details
Primary carer’s name:
Address:
Post Code:
Mobile number:
Home phone number:
Email address:
@
What information would you like to receive? (Tick all that apply)
Note: We are only able to send regular information by email.
I would like to receive:
□ Information from the Short Breaks Outreach Worker about activities, support groups etc.
□ Quarterly MOSAIC In Touch Newsletter
We would prefer to email you the Newsletter however please tick the box if you would like to receive it
through the post
□
Contact Us:
For more information visit the Camden website:
www.camden.gov.uk/shortbreaks
If you would like to speak to someone about short breaks for your disabled child or if you need help in
completing this form then please contact:
Short Breaks Outreach Worker
020 3317 2226
Details of person completing the form:
Name: ____________________________________________________________________
Relationship to child: _________________________________________________________
Signature: _________________________________________________________________
Date: _____________________________________________________________________
Please return this form to:
Short Breaks, MOSAIC, Kentish Town Health Centre,
2 Bartholomew Road, London, NW5 2BX
Registering your child on In Touch does not guarantee your eligibility for services.
Each child’s needs will continue to be considered on an individual basis.
All information held on In Touch will be treated in the strictest confidence and is protected in accordance with the Data
Protection Act 1998. Your signature on this form implies your consent for Camden Council to store your data within the
Council systems.