Family Training Application Form

Please enter your contact information

First Name(*)

Please let us know your first name.

Email Address(*)

Please let us know your email address.

Your Address(*)

Please let us know your address

Post Code(*)

Please let us know your post code

Last Name(*)

Please let us know your last name

Phone Number(*)

Please let us know your telephone number

Town/City(*)

Please let us know which town or city you live in

Reason for application

Please tick one of the below categories that you feel you want support with.

Please Tick(*)

Autism – What is autism

Behaviour management – why is the behaviour happening

Reinforcement and how to use it proactively

Pairing – building rapport with your child

Expanding interests and paly skills

Fussy eaters

Other

Please let us know which category you would like help with

Please describe in as much detail as you why you have chosen the above category and what issues you have been facing. (*)

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If you clicked ‘Other’ Please describe in as much detail as you can the training you feel would be beneficial to you if it was not listed above.

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Childs Information

Childs First Name(*)

Please enter the childs first name

Childs Last Name(*)

Please enter the childs last name

Childs Age(*)

Childs age e.g. 3 years 6 months

Gender(*)

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Date of Birth(*)

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Please list any interventions your child is currently having and with whom

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Provided By

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How Often

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Training Sessions

Training courses are either ½ day, full day or over 2 days depending on the training course itself – we do have a limited number of places so please tick which days and time frames are best for you and your family to attend a course at your home.

Weekdays

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Weekends

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Please tick to confirm that if you decide the Training is not for you will let us know as soon as possible, we always have a waiting list

I agree to inform you asap if I do not want a place when offered (*)

I Agree

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Payment

To support the cost of a REACH North West ‘Training Service’ we invite families to make a voluntary donation towards the 12 sessions rather than request a set payment.

Please confirm you are happy with a donation for the sessions(*)

YesNo

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Reach North West is a voluntary group that rely on supporters and volunteers. Would you be able to help in any of the following ways?

Please tick those you are able to help out with.

VolunteerHelp FundraisingDonate FinanciallyPromote us on a larger platformOther Invalid Input

Please let us know in which way you could help

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If you have any other questions please use this box

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How Did You Hear About REACH North West? (*)

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I Agree To REACH North West storing my data supplied on this form. (*)

Agree

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Send Application

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