Yorkshire's Specialist S.E.N.D College.

We have vacancies, please click here to view.

Respite Care Application

Respite Initial Application Form

Introduction

Respite Initial Application Form

This online application form is to provide Camphill Wakefield with a range of information upon which we can decide whether we can provide respite care and at what cost.  You will be advised of the outcome.  A further application form will only be required should there be any change in the individual’s circumstances e.g., change in support/care needs, health, behaviour or medication, etc.

For each individual period of respite care an additional booking form must be completed.  A booking is not finalised until a confirmation agreement is signed by all parties.  

General information

Notes:

  • A separate booking form will need to be completed for each period of respite care.
  • If further, additional or specific medical/care/support is identified as being required, this will be subject to an additional fee (eg requirement for working night staff, administration of medication or a specialist intervention as per a prescribed clinical protocol by a specified professional).
  • Pocket money of £10 per weekend is recommended to cover any incidental items purchased off site.
  • Students will be required to pay for any meals or activities undertaken off site. 

Student / Applicant Details

Gender

EMERGENCY CONTACT DETAILS: 1 (Please give a secondary contact in case of emergency?)

EMERGENCY CONTACT DETAILS: 2 (Please give details of anyone else to be contacted in an emergency?)

Health And Care Details

Does the applicant have Epliepsy
If Yes
a) Please give more details re frequency and (if known) triggers of episodes
b) Is the condition stable? If so is this through medication
c) What medication is taken, amount, frequency etc.
d) Is emergency medicine required
e) Does any special procedure need to be followed in the event of a seizure?

MEDICAL or PROFESSIONAL REFERRALS please give details

Please provide details of any pending or awaited medical referrals that are not covered elsewhere in this form. This should include anything that has been discussed with a GP or Social Worker but further action not yet taken.

Likes and Dislikes (please include foods as well as activities)

Personal Care etc. Please complete all that apply – please give full and detailed information as this enables us to fully consider how we can meet the applicants needs

1. Can the applicant care for his/ her own personal hygiene? Eg washing, dressing, etc.
2. Is the applicant incontinent?.
3. Do they need reminding to use the toilet?
4. Can they use the toilet independently?
5. If applicable – Does the applicant shave?
6. If applicable - does the applicant require help with her period?
7. Can they make the bed and care for their room?
8. Can they choose their own clothes and dress themselves?
10. Can they get ready for bed unaided?
11. Can they get up in a morning without assistance?
12. Is any assistance required during the night?
13. Does the applicant have any problems sleeping?
14. Does the applicant have disturbed nights – eg do they get up and wander around at night? *
15. Does the applicant have any allergies?
19. Can the applicant distinguish between reality and fantasy?
20. Is the applicant sexually aware?
21. Are there any inappropriate sexual behaviours of which we should be aware?
22. Are there any issues concerning relationships/sexuality that it would be helpful for us to know about?

ANY OTHER INFORMATION?

Please use the upload button below if you feel you need to provide more information than can be fitted in here.
Upload
Maximum upload size: 516MB

DECLARATION

Declaration by person responsible for application.

To the best of my knowledge, the information submitted on this form is correct and accurate. I confirm that I am aware that failure to reveal relevant information could result in the early termination of placement.

Instructions

Enter your name in the box below followed a signature. You can either draw your signature or type it using the icons shown on the right of the signature.

Important

This signature will be regarded as if you had signed a normal document.

Copyright © Camphill Wakefield 2018

Download our brochure

We Accept Young People With Special Educational Needs And Disabilities From All Areas Of The United Kingdom.
envelopeuserphone linkedin facebook pinterest youtube rss twitter instagram facebook-blank rss-blank linkedin-blank pinterest youtube twitter instagram