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: *Telephone 1:
Telephone 2: *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 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)
How did you hear about the programme? (select from dropdown)  
Please let us know any further details relevant to your answers. (Please do not include any medical details here) :

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