SENSORY STUDIO APPLICATION FORM

Before you can book to use the sensory studio you will need to complete this form and provide proof of Disability Living Allowance (DLA). If you are not receiving DLA but still want to book the room then please advise us of details of circumstances.

Alternatively you can download and print the form so that the form can be completed by hand and mailed (or scanned and emailed) to us at Ellie's Haven, Duloe, Liskeard, Cornwall PL14 4PW, info@ellies-haven.org.uk

Details of person registering:
Name*
Address*
Tel
Email*
Name of the child
Relationship to the child
Is the child receiving DLA or PIP?*
Please note that all sessions will last a maximum of 90 minutes and children must not be left alone at any time. If there are any accidents they must be reported immediately to a member of staff and logged in the accident book. If anything needs clearing up please advise a member of staff who will deal with it. No food or drinks are allowed in the sensory studio.

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Please check that you have entered your details correctly before clicking the Submit button.
By submitting this form, you confirm that you agree to the above data being held in a secure database by Ellie's Haven. It will be used to assess your elegibility for use of the sensory studio at Ellie's Haven and will not be passed on to third parties without your consent.

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Tel: 01503 264230
Ellie's Haven - Cornwall Ltd. Charity No: 1121426 Registered in England & Wales No: 006345083. Registered address: Plym House, 3 Longbridge Road, Marsh Mills, Plymouth PL6 8LT

Last updated 22nd January 2021		Website developed by WesternWeb