Registration Form for Neurodiversity Ireland

Child’s first name: *

Child’s surname: *

Gender: *

Male

Female

Primary contact first name: *

Secondary Contact name: *

Emergency contact name:

Allergic reactions - Severity: *

Very high

High

Medium

Low

Medical conditions, if any:

Does your child have any dietary requirements?:

Yes

Details of dietary restrictions or requirements:

What are your child's communication needs and style (e.g., what level of support they may require for their communication, how best to communicate with them, any use of Augmentative and Alternative Communication (AAC) etc.): *

N/A

Relevant diagnoses/descriptions of your child's needs: *

N/A

Please describe your child's toileting needs/toileting routine: *

N/A

What is your child's preferred play style? Please provide as much detail as possible: *

N/A

Does your child have any sensory differences/preferences that you are aware of? Please describe: *

N/A

Are there any known triggers / dislikes that we should know about in advance to best support your child?: *

N/A

Please provide details of self-regulation techniques, external regulation strategies, and preferred calming activities that work best for your child: *

N/A

Any other relevant information:

N/A

Dismissal password: *

What services are you interested in attending ?: Registration forms are viewed on a first-come, first-served basis. The availability of programs may depend on demand and capacity. Upon review of your registration form, the Sensory Centre Manager will contact you regarding you child's placement in our programs or on the waitlist. Please use your parent centre dashboard to stay updated on the status of your registration. *

OT Guided Groups (Mondays, Wednesdays, Thursdays, and Fridays)

Afternoon Club (Mondays & Wednesdays)

Art Therapy (Thursdays & Saturdays)

Gymnastics (Tuesdays)

Bar Monkey (Saturdays)

What day/time of the week is your child available to attend OT Guided Groups?: OT Guided Groups are designed with the needs of your child in mind. Groups are selected based on your child's profile using the details you included in your Sensory Centre registration form. We can not confirm that the group on your selected day will be an appropriate fit for your child. Please select any day(s) and time(s) you are available for, not just your most preferred. This will provide your child with a better opportunity at obtaining a spot in our OT Guided Groups. *

Monday 4:15PM

Monday 5:30PM

Wednesday 4:15PM

Wednesday 5:30PM

Thursday 1:00PM

Thursday 2:30PM

Thursday 4:00PM

Friday 2:45PM

Friday 4:00PM

Friday 5:15PM

None

Are you interested in Sensory Centre Camps? Please select which sessions you're interested in: Sensory Centre Camps will run during Mid-term Break, Easter Break, & Summer holidays. For more information on Camps please email bailey@neurodiversityireland.com

Mid-term Break

Easter Break

Summer

Consent for using images & videos of child:

I agree that my child can be photograhped or videoed for the sole purpose of sharing their activity and daily updates with me:

Yes No

I agree that my child can be included in photos published on social media:

Yes No

I agree that my child can be videoed for social media sites:

Yes No

Consent for medical treatment:

I give permission to apply plasters if needed:

Yes No

I agree that my child can be given first aid if required:

Yes No

I authorise the centre to allow the emergency contacts to pick up my child if I/the named guardians cannot be reached:

Yes No

I accept the terms and conditions of Neurodiversity Ireland's Sensory Centre

Yes No

Create New Field

Choose field type

Short text

Long text

Single choice

Multiple choice

Website

Phone number

Number

Create New Field

Choose field type

Short text

Long text

Single choice

Multiple choice

Website

Phone number

Number

Create New Field

Choose field type

Short text

Long text

Single choice

Multiple choice

Website

Phone number

Number

Create New Field

Choose field type

Short text

Long text

Single choice

Multiple choice

Website

Phone number

Number

Create New Field

Choose field type

Short text

Long text

Single choice

Multiple choice

Website

Phone number

Number

Create New Field

Choose field type

Multiple choice

Create New Field

Choose field type

Short text

Long text

Single choice

Multiple choice

Website

Phone number

Number

Neurodiversity Ireland

Profile

Contacts

Emergency

Medical

Other

Consents

Terms