Local Offer Request form

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Derby City Council Families Information Service would like to make the information that you have provided about your service available to members of the public, professional that work with families and services which parents use. All information provided will be treated in confidence and in accordance with the Data Protection Act 1998. It will be used by the Family Information Service and supplied to the public and on the internet only if you have provided your consent.

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

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* 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
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

Local Offer Request form

Contact details for public enquires

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

Services

Opening Times

Referral route for service

Service Eligibility

Contact the Council »