Wiltshire Parent Carer Council Registration Form Please complete, if you are not already registered and you wish to be added to the WPCC database, so that we can send you information on a regular basis
PARENT CARER CONTACT DETAILS Name……………………………………………………………………………………………………………………….. Address……………………………………………………………………………………………… Postcode ……………………….. Telephone number: ……………………………………… Mobile…….………………….. Email….………….…………….……….. OTHER INFORMATION: ETHNICITY? (E.g. White/British etc.) ……………………………………………………………………………………………………………………… ABOUT YOUR CHILD/REN WITH A DISABILITY or ADDITIONAL NEEDS
Tear this page off and post to the address below
No. of Children/Young People with a disability in your family: …………….…….. Child Name
Date of Birth
Diagnosis
1st Child
……………………………..
…………………………..
…………………….……………………………………….
2nd Child
……………………………..
…………………………..
…………………..…………………………………………
3rd Child
……………………………..
………………………….
…………………………………………………………….
SCHOOL NAME AND TYPE: (E.g. Rowdeford/Special school) 1st Child………………………………………………………………………………………………………………………………………………. 2nd Child…………………………………………………………………………………………………………………………………………….. 3rdChild……………………………………………………………………………………………………………………………………………….. By signing, I agree to the Wiltshire Parent Carer Council (WPCC) holding this information on a secure computer database so that WPCC volunteer Parent Representatives and/or SENDIS Information Officers may contact me directly. Furthermore, I understand that the WPCC subscribes to ‘yourmailinglistprovider’ and ‘Sinch’ and that if I have provided an email address or mobile telephone number, these will be added to WPCC’s subscription providers. You may unsubscribe and ask to be removed from our database at any time by contacting us or clicking ’Unsubscribe’.
SIGNED ……………………………………………………………………….. Date…………………………………………………………..
Return Address: FREEPOST WPCC (No Stamp or Address Needed) 24
