Local Offer Request form

Derby City Council would like to make the information that you have provided about your service available to members of the public, professionals that work with families, and services which parents use.

We will treat all information provided in confidence and in accordance with our privacy notice.

The fields marked with an asterisk (*) are required fields. All the information you enter will be submitted securely.

* Provider name

* Address where activity takes place

Contact details for public enquires

Name

Tel. No (No spaces)

Mobile (if appropriate)

Email

Confirm Email

Email addresses do not match.

Website

Correspondence details - we need this information to contact you to check the above details are up to date, they will not appear on our website

* Contact name

* Address

* Tel. No. (No spaces)

* Email

* Confirm Email

Email addresses do not match.

Services

* Please provide a description of the services that you provide.

For each service, please include details such as:

• Activity name
• Age range
• Cost
• Description of the service

* Service Availability

Please select All Year School holidays Term time only

Opening Times

* Monday

* Tuesday

* Wednesday

* Thursday

* Friday

* Saturday

* Sunday

Referral route for service

* Referral route for service

Application form via school

Attendance by professional referral

Drop in

Self referral

Service Eligibility

* Service Eligibility

Available To All - A Universal Service

Available To Anyone With A Difficulty Or Disability

Available To People Social

Emotional And Mental Heath Needs

Available To People With A Hearing Impairment

Available To People With A Moderate Learning Difficulty

Available To People With A Physical Disability

Available To People With A Profound Learning Difficulty

Available To People With A Severe Learning Difficulty

Available To People With A Specific Learning Difficulty

Available To People With A Visual Impairment

Available To People With An Autism Spectrum Disorder

Available To People With Behaviour

Emotional And Social Difficulty

Available To People With Speech

Language And Communications Needs

Only Available To Pupils Of The School

* Is your service aimed at children / young people with a particular need?

Yes

No

* Please state the particular need/s

Attention Deficit Hyper Activity Disorder

Autistic Spectrum

Challenging behaviours

Complex health needs

Mental health needs

Language / communication needs

Learning difficulties

Learning disabilities

Mult sensory impairment

Physical impairment

Visual impairment

Deafness

Other (please specify below)

If other, please specify