WPCC 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

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………………………………………………………………………………………………………………………………………………..

SIGNED ……………………………………………………………………….. Date…………………………………………………………..

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’ .

Return Address: FREEPOST WPCC (No Stamp or Address Needed)