Basic Information

Child's Name

Child's Date of Birth

Child's Gender
MaleFemaleOtherPrefer not to say

Address

Parents's Name

Parent Email

Parent Mobile

Questions for Your Child

What would you like to get better at by joining the Ready for Physio group? (e.g. not tripping over, feeling stronger, joining in with games, making friends, feeling more confident)

How well do you think you can do this right now? (1 = Not able at all, 10 = Very good)
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How happy are you with how you do it now? (1 = Not happy, 10 = Very happy)
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How much physical activity do you do each day? (Things like running, jumping, dancing, playing outside)
0–15 minutes15-30 minutes30–45 minutes45–60 minutes60+ minutes

Is there anything that makes it hard for you to join in with physical activities or group games? (e.g. noise, too many people, not knowing what to do, feeling nervous)

How confident do you feel about your physical skills? (e.g. running, jumping, balancing, catching)
I don’t feel confidentI feel okayI feel very confident

Have you had physiotherapy before? If yes, how did you feel about it?

Was there anything that made it hard or uncomfortable for you?

Questions for Parent/Guardian

What would you like your child to get better at by joining the Ready for Physio group? (e.g. reduce trips/falls, build exercise confidence, improve balance, feel stronger, make friends)

How well do you think your child can do this right now? (1 = Not able at all, 10 = Very good)
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How happy are you with how they do it now? (1 = Not happy, 10 = Very happy)
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Has your child had physiotherapy in the past? If so, how did they respond to it?

Were there any challenges or barriers that made physiotherapy difficult for your child?

Is there anything else you think we should know, or any support we could offer to help your child take part in the sessions?

Photo Permissions

I give permission for Little Hiccups to take photographs and/or video of my child and/or family during sessions.
I grant Little Hiccups full rights to use the images resulting from the photography/video filming, and any reproductions or adaptations of the images for fundraising, publicity, or other purposes to help achieve the group’s aims. This might include (but is not limited to) the right to use them in printed and online publicity, social media, press releases, and funding applications.

You have the right to opt out at any time.

I am happy for photos and video of my child and/or family to be taken:

YesNo

Consent

By submitting this form, I confirm that the information provided is correct and I agree to communicate any changes. I give consent for my child to take part in the Ready for Physio sessions and confirm I can attend all sessions and give my child support (unless unforeseen circumstances arise).
I agree