Children Short Breaks Enquiry

Parent / carer information:

Full name: (required)

Email address: (required)

Telephone: (required)

Child / young person information:

Please complete this section with information about the child / young person who will be attending short breaks.

Full name: (required)

Date of birth: (required)

Social worker / care coordinator name: (required)

Local authority area: (required)

The information you enter into this form will be collected and stored by the charity in accordance with its privacy policy. Your information will not be shared and you can opt out at anytime. We will store your details securely. We’ll only use them to provide the service that you have requested, and communicate with you in the way(s) you selected. For full details on our privacy policy see: https://www.ne-as.org.uk/privacy-policy.

Please confirm that you understand the above: (required)

I understand

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