Thank you for your interest.

Due to consent purposes, this form should be completed by a parent or guardian. Completing this form is the first step in expressing your interest to attend The Breathe Magic Intensive Therapy Programme. Once completed, a member of the team will be in contact. They will be able to provide guidance around the next steps in signing up to attend the programme as well as answer any questions you may have about the programme.

Please note, if you are a clinician looking to make a referral please get in touch with us directly or request that the parent/guardian completes the below form. We look forward to hearing from you.

Personal Details

Fields marked with * are mandatory.

*Child’s Full Name: *Child's Date of Birth: *Child's Gender: (select from dropdown) *Parent/Guardian's Full Name: *Email: Home Phone Number:
*Mobile Phone Number: *Flat / House Number & Street: *City: *Postcode: *Country:
 

Eligibility


The following are our main eligibility criteria for young people attending Breathe Magic Camps, please tick as appropriate to confirm this applies to your child. Please be assured that a ‘no’ to any criterion doesn’t necessarily mean your child is ineligible. The answers you give should be your best estimate and will be used to inform the conversation with our Clinical Leads to inform whether the programme will be suitable for your child.

*Young person with hemiplegia - or one-sided weakness - caused by Cerebral Palsy or Acquired Brain Injury: (select from dropdown) *Aged 7-19 years at start of camp: (select from dropdown) *Able to remember sequences of 3-4 steps: (select from dropdown) *Can cooperate and attend to perform tasks in a group setting: (select from dropdown) *Able to learn at mainstream (or equivalent) level: (select from dropdown) *As the programme is delivered in English, the young person has a sufficient level of English language to understand instruction and communicate with staff: (select from dropdown) To determine if your child is clinically eligible to join our programme, we will require them to attend an in-person taster workshop. Please confirm if you can attend our workshop date - Saturday 1st November 2025 at Sea Containers London.
*Yes, my child can attend.
*Does your child have any other diagnoses, medical conditions, or allergies? If yes, please list them: *Has your child attended the Breathe Magic Intensive Therapy Programme before? (select from dropdown)
*Please let us know any further details relevant to your answers:

Programme Dates and Availability


Please note, we are a London-based organisation and our programme is generally delivered in London. We have families joining us each year from all across the UK (and sometimes even abroad!) and we are experienced in supporting families to join the programme who may live further afield.

*If your child is eligible, would you be able to attend the programme on the following dates?
28th Jul - 8th Aug 2025, London
27th Jul - 7th Aug 2026, London
Would you be interested in future dates?
Yes, please let me know.

Funding


Please note, as a not-for-profit organisation, any young person living in the UK or Northern Ireland can access a Breathe part-funded place on the programme, no matter your financial background. We are committed to offering young people additional support to access our programme in several ways, including:

- Helping you with fundraising efforts
- Assisting you in applying for individual and charity grants
- Providing access to our Breathe Magic bursary, made possible by the generosity of our supporters, if needed.

Upon referral, you will have a call with our Programme Manager to discuss all funding options, as we do not wish for cost to be a barrier to participation. A programme information and funding overview pack will be sent to you, which provides information on the different ways to fund your child’s place, and we are here to support and guide you throughout this process.

*Please indicate how you plan to secure funding for your child’s place (tick as appropriate):

We plan to self-fund in full at £6,104.
We plan to to self-fund and apply for the Breathe part-funded place of £3,979.
We are planning to fundraise with support from Breathe for a part-funded place of £3,979.
We have access to case management/other statutory funds.
We are able to pay a deposit of £500 to secure my child’s place.
*How did you hear about the programme? (select from dropdown) If other, please specify:
Would you like to sign up to our newsletter?
Yes, please sign me up.
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