January News from the Office 2 Tips from Parents / Carers 9 News from Family workers 3-6 Helpline Service / SEN National Advice Service

Transcription

1 January 2013 News from the Office 2 Tips from Parents / Carers 9 News from Family workers 3-6 Helpline Service / SEN National Advice Service 10 Positive Parent Action 5 News Termly Workshops 7 Events Massage Sessions 8 Booking form 16 Wandsworth Contact a Family, 1 Siward Road, London SW17 0LA Tel: wandsworth.office@cafamily.org.uk Charity number: Core funded by the London Borough of Wandsworth Printed by Seagull Print, Garratt Lane

2 News from Rosie in the Wandsworth Office Happy New Year to all our families and friends! Hope you enjoyed the Festive Break. Over the last three months the team has delivered workshops from the Enhanced Children s Centre, the Early Years Centre (now known as the Early Years Service) and from 166 Roehampton Lane covering topics such as understanding behaviour, toilet training, feeding issues, invisible disabilities, and DLA renewals. We have also been involved in running a Triple P parent course for parents of children 0-12 with any disability and a Cygnet training course for parents of children who have been diagnosed with Autistic Spectrum Disorder age Both courses have received positive feedback and we will be running them again. Our annual meeting was well attended and our speakers were also well received. Carol Payne gave an update on services for children with disabilities and special educational needs and Philomena Murphy, one of our colleagues from the national helpline gave a very informative session on benefits updates. We welcomed some new parents to our steering group. Our family workers continue to offer support to parents either on a 1:1 basis or in group settings in the localities. We are able to help out with information, grant and benefits applications. We continue to offer all these services as well as our events programme see inside for more details. We look forward to seeing many of you at the courses and outings on offer please get in touch if you need more information. We welcome Sevil Savi to our team she will be doing a job share with Jan McCarthy and will be based at Siward Road on Wednesdays, Thursdays and Fridays during the term times. And finally, to let you all know that Jill Caterham who is currently on maternity leave gave birth to a baby boy in September they are both doing very well. Best wishes to all, Elizabeth, Rosie, Suzanne, Jan, Ati, Sevil, Yinka and Mohammed The views expressed in this newsletter may not necessarily be those of Contact a Family. 2

3 Battersea Early Years Team News from Suzanne Tel: ext 112 / suzanne.bailey@cafamily.org.uk Drop-in advice sessions The drop-in advice sessions will continue to run every Wednesday afternoon until the halfterm. These sessions provide an opportunity for your child with special needs and/or their sibling to play alongside others in a safe and informal environment and for you to meet with other local parents to share tips and experiences. I will be there to offer information and advice on any matters relating to your child with special needs, including offering help with completing fund applications, so even if your child is at school, please do come along! When: Every Wednesday afternoon from Wednesday 9 th January until Wednesday 13 th February Where: Chesterton Centre for Children and Families, Dagnall Street, SW11 5DT. Time: 1.30pm 3.30pm Support from Contact a Family a parent s perspective When we realised there was something different about our son we spoke to someone at Stay and Play, who recommended Suzanne at Contact a Family (CaF). We found out that CaF can support us in many ways as I will explain in this letter. We were told about their monthly meetings where we could meet other parents and professionals who could help with different types of issues to help your child. We were also given a lot of advice about helping my child. We were also supported with liaising with the different professionals we had to see regarding our child s support, which included speaking to our child s teacher about separation issues, contacting people to speed up support, speaking to professionals on our behalf, giving us advice on what to do next and the list goes on. CaF also supported us in getting funding for holidays and getting kitchen equipment through charities. When my child dragged me to my lowest point they were there to help me get back. Suzanne is always available to talk to via telephone, and text communication and I will say openly that without the support from Suzanne at CaF I don t know where I will be now. She has been a rock to us and I praise the work she does for all the families she helps. 3

4 News from Yinka Roehampton Tel: / yinka.aina@cafamily.org.uk Families from Putney and Roehampton locality who are interested in our workshops please call Yinka on to book a place (Limited spaces available and crèche is available). Weekly Explore and Play Session Yinka and our other family workers will be co-facilitating a group for parents and children under five, including siblings, at the West Hill Enhanced Children s Centre. This fun session will give children the chance to play alongside others and offer parents the chance to meet together and chat with each other and other professionals who will also be on hand to offer advice and support. When: Every Monday. Where: Enhanced Children s Centre, 5 Merton Road, London SW18 5ST Time: 9.30am 11.00am Advice and Drop-in Sessions Term time only This is a family drop-in session for the Putney and Roehampton locality. Yinka will be available with other professionals to give advice on benefit, grants and any other concerns you may have or refer you on to other professionals for support. When: Wednesday January 16 th, February 13 th, and March 13 th Where: The Group room, 166, Roehampton Lane, London SW15 4HR. Time: 1.00pm pm. No appointment needed, just drop-in. Tea/Coffee morning at Putney/Roehampton There will be a Tea and Coffee morning. When: Wednesday 09 th January, 2013 and Wednesday 06 th March 2013 Where: Group room, 166, Roehampton Lane, London SW15 4HR Time: 10.00am 12.00pm Please call Yinka to confirm your attendance. A member of the Health Team will be available to give advice on your child/children s sleeping issues and any other health related issues. News from Sevil Savi Tel: / Sevil.savi@cafamily.org.uk Hello, My name is Sevil and I will be working on Wednesday mornings, Thursdays and Fridays at the Early Years Service at 1 Siward Road with parents of older children (5+). I have been working with special needs children and young people for over 17 years in a variety of settings. I have lots of experience around different disabilities and service needs. I am a qualified Makaton Regional Tutor and proficient about using alternative communication methods such us PECs, Board Maker and Wigit which I am happy to support parents and carers who needs my help with. Also, I speak Turkish and hope to use my bilingual skills within Contact Family and I look forward to supporting parents and carers. 4

5 News from Mohammed: Tooting locality (under 5 s) Tel: / or Mohammed.ismail@cafamily.org.uk I am available Monday to Friday to support any family with a disabled child aged 5 or under in the Tooting locality. I am based at Smallwood Children s Centre on Monday, Tuesday and Wednesday and you can phone me directly on or at the Early Years Service on Thursday and Friday. I can help with claiming Disability Living Allowance or access grant applications to charities for other financial help. If you would like any support, please call me on any of the above numbers and leave a message - I will get back to you. I look forward to hearing from you and meeting many of you on our Easter activities. Get Active in Wandsworth! I am very keen to hear from many of you that may like to be part of a support group or a walk group to start in the spring term 2013 at the Early Years Centre. Please get in touch. We need your input and ideas of how best to connect with other families. Somali Drop-in sessions: I am continuing the Somali Drop-in session on the second Friday of each month at the Early Years Service. When: Friday 11 th January, Friday 08 th February, Friday 08 th March Where: Early Years Service, 1 Siward Road SW17 0LA Time: 10.00am 12.00pm News from Positive Parent Action - PPA Positive Parent Action (PPA) is Wandsworth s parent forum We are a group of parents and carers of disabled children (aged 0-25 years) aiming to improve provision for all local families, whose children have additional needs. The group meets every month at the Early Years Service 1 Siward Road. We are funded by a Department of Education grant and are supported by a facilitator employed by Contact a Family, whose role is funded by Wandsworth Borough Council. We regularly attend Council planning groups and quarterly meetings with other South London parent forums and the National Network of Parent Carer Forums, giving us knowledge about local and national issues. We ve also recently provided training on how to get the most out of meetings with professionals and how to use communication Apps on the I-Pad. We want to respond to what parents need, so would really value your ideas for future training and events. Thanks very much to everyone who returned the Short Breaks questionnaire. We will report on the findings in the next edition. We have drawn a winner from those who responded - a 50 voucher was won by a family in SW18. We want to be as representative as possible, so it s important that we get as much feedback from families as we can. We would love to hear your views, so please do let us know your contact details s work best for us, but if you would prefer to be contacted by phone or post, that s fine too. Elizabeth Nasse is the forum s facilitator (Mon, Tues, Thurs, term time) elizabeth.nasse@cafamily.org.uk or positiveparentaction@yahoo.co.uk Web: Phone:

6 News from Jan McCarthy, Family Worker Tel: / Jan.mccarthy@cafamily.org.uk First time applications for Disability Living Allowance: If your child is 5 or over and you are applying for Disability Living Allowance, please ring for an appointment. You will need to bring with you relevant information that we can send with the application i.e. if your child has a Statement of Special Educational needs, the most recent copy. Any documents or reports that confirm your child s condition you do not need a diagnosis to claim DLA but it saves a lot of time if we can send evidence of your child s needs. Re-applications for Disability Living Allowance: If you need help to complete a re-application for your child s Disability Living Allowance we can help you complete the form in a group session. DLA Group sessions When: Tuesday 15th January, Wednesday 13 th March Where: Early Years Service, 1 Siward Road, London SW17 0LA Time: 10.00am am Your application will have a date on the top right hand corner that shows when your form needs to be back to the DWP, so you can work out which session would be best for you. You will need to book onto these sessions by calling the office and we will send you out an information booklet that provides information on completing the form. If you come to the session remember to bring with you relevant information that you can send with the application e.g. the most recent copy of your child s Statement of Special Educational needs and any recent letters/reports that confirm no change or a change in your child s condition or treatment. Parent/Carers Drop-in/Support Group: Children with an invisible disability aged 5 + When: Tuesday 22 nd January Where: Early Year Service, 1 Siward Road SW17 0LA Time: 10.00am 12.00pm An informal drop in for parents of children with conditions such as ADHD, ASD, OCD, Tourette s and similar invisible conditions that cause our children to behave in a way that other people find so hard to understand. We can share some behaviour techniques, positive support people have found in Wandsworth, especially around leisure, and anything else you want to discuss. Please call to book your place and please note we do not have any crèche facilities. Managing Stress for Parent/Carers When: Tuesday 26 th February Where: Early Years Service 1 Siward Road SW17 0LA Time: 10.00am 12.00pm This workshop is aimed to help you identify the causes of stress, recognising the signs in yourself; dealing with these and getting support and help. Please call to book your place and please note we do not have any crèche facilities. 6

7 Enhanced Children s Centre workshops creche available if booked in advance We are running a series of workshops next term, so if you are not able to come this time, we will be repeating them. We have had some great feedback from parents who have attended these workshops, one Mum has successfully potty trained her child and another has found a new technique that helped her child with coping with change. They are very informal, small groups so we can discuss individual issues in the group setting Toilet training for children with additional needs can present some unique challenges. We will cover many aspects and offer some ideas for you to try out with your child. Behaviours in young children with additional needs can present a challenge. If you are having difficulty in understanding or managing some of your child s behaviour then come along and get some tips. NB This course is not available to parents who have already done the EarlyBird training. Facilitators will be Jan McCarthy and Rosie Noble covering EarlyBird, Cygnet and Triple P parenting programmes. Does your child present difficulties around Food and Feeding? At a recent group meeting talking about stress in parents, this issue came out as the top trigger so do come along and hear about what you can do to help your child. We need to know in advance if you need to book your child (up to age 5) into the crèche. Please note spaces are limited and will be allocated on a first come first served basis. Where: Enhanced Children s Centre, West Hill, 5 Merton Road, Wandsworth SW18 4HX Travel/Transport: Buses: 28, 37, 39, 44, 87, 156, 170, 220, 270, 337 and 485 Time: 10.00am pm Booking is essential for these workshops. please either call us on , or Wandsworth.office@cafamily.org.uk Toilet training Tuesday 05 th February Open to all Confirm by 29 th January and request creche places Toilet training Thursday 12 th February Open to all Let us know by 5 th February and request creche places Understanding behaviour Tuesday 05 th March Open to all Let us know by 26 th February and request creche places Feeding issues Tuesday 16 th April Open to all Let us know by 28 th March and request creche places 7

8 Massage sessions We are delighted to offer more massage sessions. The following dates are available: Friday 11 th January 9.45am-1.00pm Friday 25 th January 9.45am-1.00pm Friday 08 th February 9.45am-1.00pm Friday 01 st March 9.45am-1.00pm Friday 15 th March 9.45am-1.00pm Treatments are 40 minutes and are at the reduced rate of just In addition, we are also inviting you to come and use our lovely massage chair to ease those aches away. The use of the massage chair is free and you can use it for up to 30 minutes, but please do call us so that we can offer you an allocated time for either service. To book your appointment, please call In order to secure your place you must pay in advance for all massage sessions booked with Caroline. Introduction to Autism Spectrum Disorder for family and friends - Early Years service This is a New Workshop for the extended family and friends. We will cover information about ASD, communication, behaviour strategies, as well as how to support the family after the diagnosis. When: Monday 04 th February Where: Early Years Service, 1 Siward Road. SW17 0LA Time: 12.30pm 3.00pm Or When: Tuesday 12 th February Where: Early Years Service, 1 Siward Road. SW17 0LA Time: 5.30pm 8.00pm To book a place please ring Laurain McCarthy or Sue Price or Lmccarthyl@wandsworth.gov.uk or sprice@wandsworth.gov.uk 8

9 Tips please! While we do our best to find out as much as we can about local information and services, we find that we are unable to beat the invaluable help you are able to provide from your own personal experiences. We would like to dedicate a page to tips you may wish to share with other parents. Did you receive a tip from a professional or parent which you found worked particularly well for your child, have you had a particularly positive experience at a shop/venue/restaurant which may have been particularly welcoming to your child and family? These are just examples. The list is endless! Any tip you may wish to share would no doubt be invaluable to other parents in the area, so it would be great if you could share them with us! Send your tips to wandsworth.office@cafamily.org.uk or write to us at Contact a Family, Early Years Service, 1 Siward Road SW17 0LA. Thanks for your help! Tips from parents Tip no 1 The Dentist that you referred my son to has given me a great tip. She told me to make sure that all toothpastes contain a minimum of 1400ppm. She said if it's less than that it doesn't have enough flouride and will not clean the teeth properly. She suggested SpongeBob Squarepants toothpaste, bubble gum flavoured. I must say I can see the difference! The original toothpaste I was using for my son only had 500ppm and that definitely has contributed to his teeth being in such a bad way. The SpongeBob toothpaste I've found to be very good and his breath just smells better. Tip no 2 One of our parents has an 11 year old daughter whose condition causes her to suffer from huge mood swings that can lead to very difficult behaviour. Mum has come up with some very effective ways of letting friends and family know what mood her daughter is in. She has used the colours of traffic lights red, yellow and green to help her daughter indicate this to friends, family and school. Together they have made mood bracelets using beads and bands bought cheaply from the Early Learning Centre. This young lady has dyspraxia so threading the beads also helps her fine motor skills. A red bracelet means don t talk to me, yellow means I will talk to you but don t talk too much and green means I am in a good mood. Mum has also bought coloured tape and put it on the end of pencils so in class the teacher and friends can see what mood her daughter is in. Another resource mum has used is The Girls Book of Secrets: Shhh... Don t Tell! These books are promoted as All the skills you need to survive and thrive, no matter what life throws at you in one super-cool book just for girls (and boys). This mum has used these to help her daughter understand how to manage in social situations. They have also devised a code that her daughter uses to indicate to mum how she is feeling when she picks her up from school etc. They will have worked out what sort of code they are going to use. So it could be the way she is wearing her uniform, what position she has her arms in very simple things that don t cost anything! 9

10 Contact a Family HELPLINE and The SEN National Advice Service The new SEN National Advice Service is part of our existing integrated Helpline/Online service for families. It is a one stop shop for parents and other family members caring for a child with SEN, on all education issues. The telephone helpline will enable parents and carers to get one-to-one, in-depth and personalised advice from our SEN advisers. The SEN Service covers comprehensive advice on a broad range of issues related to special educational needs in any education setting. Online services are available for more general advice and guidance, via helpline@cafamily.org.uk or our website: Facebook and Twitter to enable families to engage with us and with each other. We have a wide range of free parent guides which you can obtain from the helpline. We can also put you in touch with UK-wide and local support groups. Many families like to share experiences with others caring for a disabled child and find the support this can bring invaluable. If your child has a rare disorder and there isn't a group we might be able to link you with another family on a one-to-one basis. For more information please contact: Tel: helpline@cafamily.org.uk The helpline is open Monday- Friday, 9.30am-5pm. Or go to our website Need help with fuel costs this Christmas? If you're struggling with the cost of keeping your family warm this winter, our Contact a Family helpline advisers have put together some web pages that may help you. Our new pages 'Help with fuel bills' under our 'Know your rights' section covers: the financial help you may qualify for the steps you can take to keep fuel bills low your rights around disconnection and fuel debt. On average it costs three times more to raise a disabled child. Our research has shown that 1 in 6 families with disabled children are going without heating. Find out how you can help us to campaign for families of disabled children to be exempt from cuts to financial support - check our campaign pages. Web: 10

11 NEWS Generate: Transition The point at which young people with a learning disability leave school or college is a testing time both for the young person and their family unit. At Generate we believe that young people with a learning disability have the potential to make a positive transition to adulthood and with the right support replicate to a great extent the lifestyles of their non-disabled siblings and same age peers. However we also understand that their life has been different and they have often not yet been able to experience many things that would be usual for young adults they are excluded from taking responsible roles within the home, they travel on school transport and don t have skills to travel independently, they have a small circle of friends that they meet at school or college but seldom meet at evenings and weekends, they are taken to places but do not often make individual choice about their activity and are unused to planning their own time, they are more reliant on their family unit than other young adults. Most families with a young member with a learning disability will recognise the issues and the potential impact on the family unit when the routine provided by school or college ends. Each participant will be working towards building a planned weekly routine that will be sustainable into the future and we will work with them to assess the types of support they may need to take part in their chosen activities. In the early stages they will enjoy the challenge of some trial and error and later on they will work to establish a pattern of weekly activity. We hope that alliances will form within the group and that shared activity with friends will form part of their future plans. Engaging in 1-2-1, group work and youth club sessions for ages 17 ½ - 25 year olds. To refer anyone to us all you have to do is call us! For more information please contact: Nathan Lindsay or Brenda Deans on: YoungSibs Service Sibs, the UK charity for siblings of disabled people, has launched the first ever UK wide online service for siblings of disabled children. YoungSibs will provide young siblings with much needed information and support whilst they are growing up with a disabled brother or sister. The YoungSibs service has information about disability, dealing with feelings and family life, and tips for coping with difficult situations. It has a letters section for siblings to receive personalised responses to their questions, and a safe chat area for young siblings to talk to other young siblings in the UK. There is also a sibling group chat area for local sibling groups to keep in touch. YoungSibs is supported by The True Colours Trust, Esmée Fairbairn Foundation and The Rank Foundation. To find out more visit or youngsibs@sibs.org.uk 11

12 Transport for All Transport for All is the organisation representing London s disabled and older transport users. One of the most popular services is their telephone hotline offering free advice and information about accessible transport in London. They can answer queries on all aspects of accessible transport, from arranging free travel training; Blue Badge queries; help applying to Dial-A-Ride and Taxicard; and advice on bus, tube and train journeys. They can also post you Get Moving, a free 60 page booklet about accessible transport, as a booklet or as an audio book. Transport for All is free to join if you d like to join with the UK s only charity dedicated to transport accessibility you can join over the phone or online. You can also sign up to receive their e-newsletter just contactus@transportforall.org.uk or Phone The Inclusion Training Pathway Parents for Inclusion Enrolment is starting now for the one and only accredited training for parents of disabled children and those with special educational needs. Gain nationally recognised certification for what we do well and feel strongly about being a parent and supporting your family. What can you gain from the course? Skills in supporting your young people to be in control of their lives. You and your child s rights. Increased knowledge about what inclusive communities look like and why inclusion is so important. Increased confidence in yourself as a parent. How to support yourself and learn how to support others. Be inspired by the leaders of the inclusion movement. Make new friends and connect with a diverse and exciting community. For more information and a booking form contact: info@parentsforinclusion.org Or phone Pam Hall or Cornelia Broesskamp on Swimming Lessons for Physically Disabled Children Level Water is a new charity that will be offering free 1:1 swimming lessons for physically disabled children aged 4 to 12. We are sorry to say that we will not currently be teaching children with learning difficulties. We aim to start early in 2013, working in partnership with a swim school in Wandsworth. Priority will be given firstly to children already on waiting lists at other disability swimming sessions in the borough, and then will be first-come, firstserved. If you are interested, please send an to Ian Thwaites at ian@levelwater.org including your name, phone number and an overview of your child's disability. We will get back to you early in the New Year. 12

13 News from Ati Ismailmiya, Inclusion Coordinator Tel: Hello everyone, We have another fun filled events programme planned for Easter! Most of our events are over-subscribed so we will allocate places first to families who have not been to any of our events before. We do have a waiting list, so please apply even if you have been to our events before as there is a chance you may be able to go. We will send a letter or an confirming your place/s. is our preferred method of communication, so please do check your s and make sure it s not in your spam folder! If you apply for an event and are allocated a space / spaces then please try to pay by the payment deadline. We had to cancel the trip to the Guildford Spectrum in October because we allocated places to 52 people but only 12 paid by the deadline! If you are unable to make the payment by the deadline please call us on An extension for paying can be arranged but only if you call us before the deadline. If you have not paid us by the deadline or have not called us to let us know when you will pay by then we will automatically offer the tickets / places to another family on the waiting list you will not be sent a reminder. One more thing if you are collected by coach from the EYC the coach can only drop you back at the EYC. Individual drop-offs cannot be made. 13

14 EVENTS! FUN MORNING Come and join in the fun! There will be a bouncy castle and soft play area. Light refreshments are included. When: Wednesday 03 rd April, 2013 Where: Early Years Centre, 1 Siward Road SW17 OLA Time: 10.30am 12.30pm Cost: 1.00 per child (under 8 s only but older siblings are welcome just call us to let us know). Please complete the booking form and send it to us by 5pm on Thursday 31 st January, or wandsworth.office@cafamily.org.uk to let us know that you would like to come! BOCKETTS FARM We are planning a day trip to Bocketts Farm. This includes access to an animal handling session and a tractor ride! You ll need to bring your own lunch or use the facilities at the Farm. We will provide transport to and from the venue. The coach will collect us from the EYC, 1 Siward Road. Full information will be provided once your booking has been confirmed. When: Thursday 04 th April, 2013 Where: Bocketts Farm, Time: 10.00am 4.00pm Cost: 8 per person. Please send the application form by 5pm on Thursday 31 st January. 14

15 THE LONDON TRANSPORT MUSEUM London Transport Museum offers an exciting range of curriculum-linked activities and visits for all ages. Spend the day looking at the amazing displays and children can sit on a real life size bus! In fact if you wanted to make a bus with your children here is a link showing you how to build a route-master bus! When: Thursday 11th April, 2013 Where: The London Transport Museum, Covent Garden Piazza London, WC2E 7BB Time: Meet us outside the Transport museum at 11am. Cost: Please note the admission fee is normally for adults and for concessions. You only have to pay 2.50 per adult for this trip. Please complete the booking form and send it to us by 5pm on Thursday 31 st January, or wandsworth.office@cafamily.org.uk to let us know that you would like to come! Full details provided once you send your form in. Charlie and the Chocolate Factory When Charlie wins a golden ticket to the weird and wonderful Wonka Chocolate Factory, it's the chance of a lifetime to feast on the sweets he's always dreamed of. But beyond the gates astonishment awaits, as down the sugary corridors and amongst the incredible edible delights, the five lucky winners discover not everything is as sweet as it seems! Thanks to Short Breaks Funding we have secured a limited number of tickets to watch this new musical. Priority will be given to families who have not been on any theatre trips. When: Saturday 18 th May, 2013 Where: Theatre Royal Drury Lane Time: 7.30pm Cost: 7.00 per person. Please send the application form by 5pm on Thursday 31 st January. 15

16 EVENTS BOOKING FORM PLEASE DETACH AND POST/FAX OR TO US BY 5PM ON THURSDAY 31 ST JANUARY. Event Date Time Cost No of Adults No of Children Ages of Children Fun Morning Bocketts Farm Wed 03 rd April Thurs 04 th April 10.30am pm 10.00am- 3.30pm 1.00 per child 8.00 per person London Transport Museum Thurs 11 th April pm 2.50 per adult Charlie and the Chocolate Factory Sat 18 th May 7.30pm 7.00 per person Please sign the page and send the form back us at Contact a Family, 1 Siward Road London SW17 0LA or you can scan and the form to wandsworth.office@cafamily.org.uk or you can send your request directly in the body of an at the same address please provide your full name, contact details, the number of adults and children and which event/s you would like to attend. Please also indicate if you require assistance on the day or if your child is a wheelchair user so that we can accommodate your needs in advance. We will let you know by Thursday 21 st February by letter or if you have been allocated places at any of the events. We will also let you know where and when to meet us. YOU MUST COMPLETE THE SECTION BELOW. PLEASE FILL IN ALL OF THE BOXES. PLEASE DO NOT SEND PAYMENT WITH THIS FORM. Adults full name: Children s full name: Home number: Address: address: Mobile number: PLEASE PRINT YOUR NAME: SIGNATURE: DATE: 16