Parent/carers Name *

First Name

Last Name

Would you be interested in an autism specific swim school for children? *

Yes

No

The swim school would be for children aged from 5-16, would this interest you for your child? *

Yes

No

If this ratio would not work for your child, would you be interested in paying for one-one sessions? *

Yes

No

Prices at Fusion leisure centre for one-one swimming coaching are £25, would you be interested in this? *

Yes

No

Your opinion is very important, we value your input. Please can we have permission to share the results of this research with Fusion leisure center for the purpose only to help develop inclusive swimming lessons? *

Yes, i give permission

No, i do not give permission

Are you aware that Zebras Charity has a Recreation Fund, where applicants can apply for up to £100 per year to help towards activities of their choice? *

Yes

No

Would you be interested in applying for the Recreation Fund to help towards potential autism swimming lessons? *

Yes

No

Maybe

Name *

First Name

Last Name

What activities would you like at the Childrens Club? *

Lego Session

Star Gazing Group

Arts and Crafts

Drama/Acting/Singing

Minecraft/Gaming

Gardening

Animal care

Model Railway

Movie nights

Book Club/Stories

Sensory Play

Music Session

Other

Please confirm you have read the information below: *

Zebras Children's Club - as before, is run as a stay and play. Therefore parents and carers are to stay with the children at all times. Holiday clubs would be ran with this same format.

I Understand

Would you be interested in volunteering at one of the sessions? *

Yes

No

Parent/Carer/Professional Name *

First Name

Last Name

Do you know a child/children who would be interested in attending Zebras Children's Club? *

Yes

No

Do you know a child/children who would like free membership? *

Yes

No

Would you like us to notify you when there is more information? *

Yes

No

Name *

First Name

Last Name

Remain Anonymous *

Yes

No

I give permission for the below statement to be used as supportive evidence for Zebras Children and Adults Charity application for National Lottery Reaching communities funding only. *

I Agree

I Disagree

Name *

First Name

Last Name

Would you like to be added to our mailing list? *

Yes

No

Are you a *

A disabled person

Person with a chronic health condition

Person with mental health difficulties

Carer

Parent to a child/adult child with disabilities

Have you ever received emotional support? *

Yes

No

Do you suffer from any of the following emotional difficulties *

Emotional psychological distress

Anxiety

Depression/Low mood

Feeling out of control

Trauma

Isolation

Addiction

Employment or Financial stress

None of the above

Is your GP aware of any emotional difficulties you have? *

Yes

No

Did you have to pay for this service? *

Yes

No

Would you be interested in free emotional support? *

Yes

No

Are you aware of what life coaching is? *

Yes

No

I would like to learn more

Would you be interested in joining a emotional support group? *

Yes

No

Would you be interested in volunteering as a member within a support group to help others? *

Yes

No

Would you be interested in leading a support group? *

Yes

No

Have you heard of mindfulness? *

Yes

No

Would you like to come along to a weekly well-being hub? *

Yes

No

Please tell me more

Name *

First Name

Last Name

Would you like to join our Mailing List? *

Verification Email will be sent shortly

Yes

No

Are you a: *

Person With Disabilities

Carer

Parent To Child With Disabilities

Parent To Adult Child With Disabilities

Support Worker

Other Professional Person

Would you be interested in the services that Fusion Leisure Center Southbury Road Enfield have to offer? *

Yes

No

Would you be interested in a specific special needs soft play time? *

Yes

No

Would you be interested in multi-sport family fun sessions? *

Yes

No

Are you aware Carers go free at Fusion Leisure Center Southbury Road Enfield *

Yes

No

Zebras Children and Adults Charity provides funding for recreation activities would you like to find out more and apply? *

Yes

No (But please E-mail me more Information)

No

Name *

First Name

Last Name

Would you like to join our Mailing List? *

Verification E-mail will be sent shortly

Yes

No

Are You A: *

Person With Disabilities

Carer

Parent To Adult Child With Disabilities

Support Worker

Other Professional Person

Would you be interested in the services that Fusion Leisure Center Southbury Road Enfield have to offer? *

Yes

No

Are you aware Carers go free at Fusion Leisure Center Southbury Road Enfield *

Yes

No

Zebras Children and Adults Charity provides funding for recreation activities would you like to find out more and apply? *

Yes

No (But I would like to receive information about this)

No