Parent/Carer Contact & Consent Form Question Title * 1. Your Name: Question Title * 2. Your Contact Telephone Number: Question Title * 3. Your Email Address: Question Title * 4. Child/Young Person's Name: Question Title * 5. Child/Young Person's Age: Question Title * 6. Child/Young Person's Date of Birth: Date / Time Date Question Title * 7. Which race/ethnicity best describes your Child/Young Person? (Please choose only one) Any other ethnic background Asian or Asian British - Bangladeshi Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Any other Asian background Black or Black British - African Black or Black British - Caribbean Black or Black British - Any other Black background Chinese Does not wish to be recorded Gypsy / Roma Mixed - Other mixed background Mixed - White and Asian Mixed - White and Black African Mixed - White and Black Caribbean Traveller of Irish heritage White British White Irish Question Title * 8. Your Relationship to the Child/Young Person: Question Title * 9. Nursery, School or College your Child/Young Person attends: Question Title * 10. Reason for contacting us, please add as much information about your enquiry below: Question Title * 11. Consent: Havering SENDIASS provide independent support for Havering residents. When staff support you, we require your consent to speak with other professionals on your behalf. If you are happy for us to do this, please read the statement and sign below. I hereby give my consent for Havering SENDIASS to access files held by the Havering Children & Adults with Disabilities Team (CAD). In addition to this, where necessary to speak to other professionals to find out more information on my behalf. I give Havering SENDIASS my consent I do not give Havering SENDIASS my consent Done