Registration Form (Local Authority) Please complete our registration form Resident Parent/Guardian Name * First Name Last Name Relationship to Child(ren) * Address where Child(ren) reside * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent Email Parent Phone Solicitors Name & Solicitor Practice * Solicitor Address Address 1 Address 2 City State/Province Zip/Postal Code Country Solicitors Phone number Case Number/Reference Child(ren) Details * Name/Sex/Date of Birth Adult Name Requesting Contact * First Name Last Name Relationship To Child(ren) * Does this person have legal parental responsibility * Yes No Time since last met child(ren) * Time since lived with child(ren) * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Solicitors Name & Practice Name * Solicitor Address Address 1 Address 2 City State/Province Zip/Postal Code Country Solicitors Phone Number * Case Number/Reference Referrer Name * First Name Last Name Profession * Referrer Address Address 1 Address 2 City State/Province Zip/Postal Code Country Referrer Phone Number * CAFCASS Officer allocated? * Yes No CAFCASS Details Officer/Address/Phone Number Where & when did contact last take place * Is there a court order relating to the contact * If yes please email details to c4fcic@gmail.com Yes No Other court orders Please detail any other court order that have been made in relation tot he child(ren) Is there an agreement with all parties that the child(ren) can be taken out of the centre? * Yes No What is the next court date? If none please leave blank MM DD YYYY Are the parents willing to meet? * At the Child Contact Centre Yes No Who will be bringing the child(ren)? * Drop off service required? Yes No Preferred date of first contact at centre MM DD YYYY How frequently will contact take place? Once a week Once every 2 weeks Once per month Other How long will each visit last? 15 mins 30 mins 45 mins 60 mins Other Names of authorised participants in contact at the Centre Name/Relationship to Child Child Safety * Are there or have there been sexual/child abuse allegations made in the family? Yes No Child Safety * Has any person who will be involved int he contact ever been convicted of an offence against a child(ren)? Yes No Child Safety * Is the family know to social services? Yes No Child Safety * Has there ever been or is there likely to be a risk of abduction? Yes No If 'Yes' has been answered to any of the above then please detail below Please include details for any procedures for holding passports, Social service details, convictions, abuse or reports of violence involving either party, children or respective families. Health & Medical * Do any of the children have any illness, allergy, disability, special needs or medial needs? Yes No If 'Yes' Please detail Health & Medical * Do any of the adults suffer from long term physical/mental health illness or a disability? Yes No Download Centre Rules If yes then please detail below Language What language is spoken at home? * Is an interpreter required? Yes No If 'Yes' then please provide name and organisation details of the interpreter to be used in the session(s) Has this family ever used another Child Contact Centre? * Yes No If 'Yes' please provide details below Additional information Please provide any relevant background information. Confirmation statement * I have emailed any court order or direction or any written agreement between the parties. I have explained the rules of the Child Contact Centre to my client and given them a copy of the Centre’s leaflet / guidelines. This form has been completed to the best of my knowledge. Thank you. We’ll be in touch shortly. Download Centre Rules
