{"id":21031,"date":"2024-04-08T13:03:23","date_gmt":"2024-04-08T13:03:23","guid":{"rendered":"https:\/\/newlifecharity.co.uk\/?page_id=21031"},"modified":"2024-04-08T13:03:23","modified_gmt":"2024-04-08T13:03:23","slug":"play-therapy-pod-application-form","status":"publish","type":"page","link":"https:\/\/newlifecharity.co.uk\/play-therapy-pod-application-form\/","title":{"rendered":"Play Therapy Pod Application Form"},"content":{"rendered":"<div id=\"quform-e9596d\" class=\"quform quform-4 quform-support-page-caching quform-is-first-page\"><form id=\"quform-form-e9596d\" class=\"quform-form quform-form-4\" action=\"\/wp-json\/wp\/v2\/pages\/21031#quform-e9596d\" method=\"post\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" 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qtip-shadow&quot;,&quot;tooltipMy&quot;:&quot;left center&quot;,&quot;tooltipAt&quot;:&quot;right center&quot;,&quot;isRtl&quot;:false,&quot;scrollOffset&quot;:-50,&quot;scrollSpeed&quot;:800}\"><button class=\"quform-default-submit\" name=\"quform_submit\" type=\"submit\" value=\"submit\" aria-hidden=\"true\" tabindex=\"-1\"><\/button><div class=\"quform-form-inner quform-form-inner-4\"><input type=\"hidden\" name=\"quform_form_id\" value=\"4\" \/><input type=\"hidden\" name=\"quform_form_uid\" value=\"e9596d\" \/><input type=\"hidden\" name=\"quform_count\" value=\"1\" \/><input type=\"hidden\" name=\"form_url\" value=\"https:\/\/newlifecharity.co.uk\/wp-json\/wp\/v2\/pages\/21031\" \/><input type=\"hidden\" name=\"referring_url\" value=\"http:\/\/newlifecharity.co.uk\/play-therapy-pod-application-form\/\" \/><input type=\"hidden\" name=\"post_id\" value=\"\" \/><input type=\"hidden\" name=\"post_title\" value=\"\" \/><input type=\"hidden\" name=\"quform_current_page_id\" value=\"3\" \/><input type=\"hidden\" name=\"quform_csrf_token\" value=\"A9pOtF21GJbvx1AHrgFhcc5yYfIp99rx7jB2g8V9\" \/><div class=\"quform-elements quform-elements-4 quform-cf quform-responsive-elements-phone-landscape\"><div class=\"quform-page-progress quform-page-progress-type-numbers\"><div class=\"quform-page-progress-bar\" style=\"width: 20%;\"><span class=\"quform-page-progress-text\">Page <span class=\"quform-page-progress-number\">1<\/span> of 5<\/span><\/div><\/div><div class=\"quform-element quform-element-page quform-page-3 quform-page-4_3 quform-cf quform-group-style-plain quform-first-page quform-current-page\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-4_99 quform-cf\"><div class=\"quform-spacer\"><h3>Child\u2019s details<\/h3><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-4_7 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-4_8\"><div class=\"quform-element quform-element-text quform-element-4_5 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_5\"><label class=\"quform-label-text\" for=\"quform_4_5_e9596d\">First Name<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-4_5\"><div class=\"quform-input quform-input-text quform-input-4_5 quform-cf\"><input type=\"text\" id=\"quform_4_5_e9596d\" name=\"quform_4_5\" class=\"quform-field quform-field-text quform-field-4_5\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-date quform-element-4_10 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_10\"><label class=\"quform-label-text\" for=\"quform_4_10_e9596d\"> Child's Date of Birth<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-date quform-inner-4_10\"><div class=\"quform-input quform-input-date quform-input-4_10 quform-cf quform-has-field-icon-right\"><input type=\"text\" id=\"quform_4_10_e9596d\" name=\"quform_4_10\" class=\"quform-field quform-field-date quform-field-4_10\" placeholder=\"YYYY-MM-DD\" data-options=\"{&quot;format&quot;:&quot;d\\\/M\\\/yyyy&quot;,&quot;min&quot;:&quot;&quot;,&quot;max&quot;:&quot;&quot;,&quot;start&quot;:&quot;month&quot;,&quot;depth&quot;:&quot;month&quot;,&quot;showFooter&quot;:false,&quot;locale&quot;:&quot;en-US&quot;,&quot;placeholder&quot;:&quot;&quot;,&quot;autoOpen&quot;:true,&quot;identifier&quot;:&quot;4_10&quot;}\" \/><span class=\"quform-field-icon quform-field-icon-right\"><i class=\"qicon-calendar\"><\/i><\/span><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-4_9\"><div class=\"quform-element quform-element-text quform-element-4_6 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_6\"><label class=\"quform-label-text\" for=\"quform_4_6_e9596d\">Surname<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-4_6\"><div class=\"quform-input quform-input-text quform-input-4_6 quform-cf\"><input type=\"text\" id=\"quform_4_6_e9596d\" name=\"quform_4_6\" class=\"quform-field quform-field-text quform-field-4_6\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-4_11 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_11\"><label class=\"quform-label-text\" id=\"quform_4_11_e9596d_label\">Gender<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-4_11\"><div class=\"quform-input quform-input-radio quform-input-4_11 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_4_11_e9596d_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_11\" id=\"quform_4_11_e9596d_1\" class=\"quform-field quform-field-radio quform-field-4_11 quform-field-4_11_1\" value=\"Female\" \/><label for=\"quform_4_11_e9596d_1\" class=\"quform-option-label quform-option-label-4_11_1\"><span class=\"quform-option-text\">Female<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_11\" id=\"quform_4_11_e9596d_2\" class=\"quform-field quform-field-radio quform-field-4_11 quform-field-4_11_2\" value=\"Male\" \/><label for=\"quform_4_11_e9596d_2\" class=\"quform-option-label quform-option-label-4_11_2\"><span class=\"quform-option-text\">Male<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_11\" id=\"quform_4_11_e9596d_3\" class=\"quform-field quform-field-radio quform-field-4_11 quform-field-4_11_3\" value=\"Non binary\" \/><label for=\"quform_4_11_e9596d_3\" class=\"quform-option-label quform-option-label-4_11_3\"><span class=\"quform-option-text\">Non binary<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_11\" id=\"quform_4_11_e9596d_4\" class=\"quform-field quform-field-radio quform-field-4_11 quform-field-4_11_4\" value=\"Prefer Not to Say\" \/><label for=\"quform_4_11_e9596d_4\" class=\"quform-option-label quform-option-label-4_11_4\"><span class=\"quform-option-text\">Prefer Not to Say<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-4_13 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_13\"><label class=\"quform-label-text\" for=\"quform_4_13_e9596d\">Please tell us the child\/young person\u2019s diagnosis and prognosis (please attach separate sheet if required):<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-4_13\"><div class=\"quform-input quform-input-textarea quform-input-4_13 quform-cf\"><textarea id=\"quform_4_13_e9596d\" name=\"quform_4_13\" class=\"quform-field quform-field-textarea quform-field-4_13\" maxlength=\"255\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-4_14 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_14\"><label class=\"quform-label-text\" id=\"quform_4_14_e9596d_label\">Is the child\u2019s condition considered to be a:<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-4_14\"><div class=\"quform-input quform-input-radio quform-input-4_14 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_4_14_e9596d_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_14\" id=\"quform_4_14_e9596d_1\" class=\"quform-field quform-field-radio quform-field-4_14 quform-field-4_14_1\" value=\"Significant disability?\" \/><label for=\"quform_4_14_e9596d_1\" class=\"quform-option-label quform-option-label-4_14_1\"><span class=\"quform-option-text\">Significant disability?<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_14\" id=\"quform_4_14_e9596d_2\" class=\"quform-field quform-field-radio quform-field-4_14 quform-field-4_14_2\" value=\"Life threatening condition?\" \/><label for=\"quform_4_14_e9596d_2\" class=\"quform-option-label quform-option-label-4_14_2\"><span class=\"quform-option-text\">Life threatening condition?<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_14\" id=\"quform_4_14_e9596d_3\" class=\"quform-field quform-field-radio quform-field-4_14 quform-field-4_14_3\" value=\"Life limiting condition?\" \/><label for=\"quform_4_14_e9596d_3\" class=\"quform-option-label quform-option-label-4_14_3\"><span class=\"quform-option-text\">Life limiting condition?<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_14\" id=\"quform_4_14_e9596d_4\" class=\"quform-field quform-field-radio quform-field-4_14 quform-field-4_14_4\" value=\"Terminal illness?\" \/><label for=\"quform_4_14_e9596d_4\" class=\"quform-option-label quform-option-label-4_14_4\"><span class=\"quform-option-text\">Terminal illness?<\/span><\/label><\/div><\/div><\/div><p class=\"quform-description quform-description-below\">Newlife defines a significant disability as being a physical and\/or cognitive impairment which affects activities of daily living. A life-threatening condition should be defined as a condition whereby the next period of ill health would make it likely that life- sustaining intervention would be needed. Newlife defines a life-limiting condition as a condition that results in a shortened life expectancy, as opposed to having limited life experiences that could affect quality of life. A terminal illness is generally defined as not being expected to live longer than six months and\/or a person who has an advanced care plan to meet end of life care needs.<\/p><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-4_15 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_15\"><label class=\"quform-label-text\" id=\"quform_4_15_e9596d_label\">Is the child\/young person a resident of the UK?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-4_15\"><div class=\"quform-input quform-input-radio quform-input-4_15 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_4_15_e9596d_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_15\" id=\"quform_4_15_e9596d_1\" class=\"quform-field quform-field-radio quform-field-4_15 quform-field-4_15_1\" value=\"Yes\" \/><label for=\"quform_4_15_e9596d_1\" class=\"quform-option-label quform-option-label-4_15_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_15\" id=\"quform_4_15_e9596d_2\" class=\"quform-field quform-field-radio quform-field-4_15 quform-field-4_15_2\" value=\"No\" \/><label for=\"quform_4_15_e9596d_2\" class=\"quform-option-label quform-option-label-4_15_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-4_16 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_16\"><label class=\"quform-label-text\" id=\"quform_4_16_e9596d_label\">How would you describe the child\/young person\u2019s family situation? (Tick any that apply) <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-4_16\"><div class=\"quform-input quform-input-checkbox quform-input-4_16 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_4_16_e9596d_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_16[]\" id=\"quform_4_16_e9596d_1\" class=\"quform-field quform-field-checkbox quform-field-4_16 quform-field-4_16_1\" value=\"Living mainly with one parent\t\" \/><label for=\"quform_4_16_e9596d_1\" class=\"quform-option-label quform-option-label-4_16_1\"><span class=\"quform-option-text\">Living mainly with one parent\t<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_16[]\" id=\"quform_4_16_e9596d_2\" class=\"quform-field quform-field-checkbox quform-field-4_16 quform-field-4_16_2\" value=\"Living with both parents\" \/><label for=\"quform_4_16_e9596d_2\" class=\"quform-option-label quform-option-label-4_16_2\"><span class=\"quform-option-text\">Living with both parents (include step-parents) <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_16[]\" id=\"quform_4_16_e9596d_10\" class=\"quform-field quform-field-checkbox quform-field-4_16 quform-field-4_16_10\" value=\"Court issued Special Guardianship Order\" \/><label for=\"quform_4_16_e9596d_10\" class=\"quform-option-label quform-option-label-4_16_10\"><span class=\"quform-option-text\">Court issued Special Guardianship Order<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_16[]\" id=\"quform_4_16_e9596d_3\" class=\"quform-field quform-field-checkbox quform-field-4_16 quform-field-4_16_3\" value=\"Residing in School\" \/><label for=\"quform_4_16_e9596d_3\" class=\"quform-option-label quform-option-label-4_16_3\"><span class=\"quform-option-text\">Residing in School<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_16[]\" id=\"quform_4_16_e9596d_4\" class=\"quform-field quform-field-checkbox quform-field-4_16 quform-field-4_16_4\" value=\"Looked After Child Local Authority has parental responsibility\" \/><label for=\"quform_4_16_e9596d_4\" class=\"quform-option-label quform-option-label-4_16_4\"><span class=\"quform-option-text\">Looked After Child (Local Authority has parental responsibility)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_16[]\" id=\"quform_4_16_e9596d_5\" class=\"quform-field quform-field-checkbox quform-field-4_16 quform-field-4_16_5\" value=\"Residing in Care Home\" \/><label for=\"quform_4_16_e9596d_5\" class=\"quform-option-label quform-option-label-4_16_5\"><span class=\"quform-option-text\">Residing in Care Home<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_16[]\" id=\"quform_4_16_e9596d_6\" class=\"quform-field quform-field-checkbox quform-field-4_16 quform-field-4_16_6\" value=\"Living with care given at different locations, by both parents \" \/><label for=\"quform_4_16_e9596d_6\" class=\"quform-option-label quform-option-label-4_16_6\"><span class=\"quform-option-text\">Living with care given, at different locations, by both parents <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_16[]\" id=\"quform_4_16_e9596d_7\" class=\"quform-field quform-field-checkbox quform-field-4_16 quform-field-4_16_7\" value=\"Fostered\" \/><label for=\"quform_4_16_e9596d_7\" class=\"quform-option-label quform-option-label-4_16_7\"><span class=\"quform-option-text\">Fostered<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_16[]\" id=\"quform_4_16_e9596d_8\" class=\"quform-field quform-field-checkbox quform-field-4_16 quform-field-4_16_8\" value=\"Court issued Child Arrangement Order \" \/><label for=\"quform_4_16_e9596d_8\" class=\"quform-option-label quform-option-label-4_16_8\"><span class=\"quform-option-text\">Court issued Child Arrangement Order <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_16[]\" id=\"quform_4_16_e9596d_9\" class=\"quform-field quform-field-checkbox quform-field-4_16 quform-field-4_16_9\" value=\"Adopted\" \/><label for=\"quform_4_16_e9596d_9\" class=\"quform-option-label quform-option-label-4_16_9\"><span class=\"quform-option-text\">Adopted<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_16[]\" id=\"quform_4_16_e9596d_11\" class=\"quform-field quform-field-checkbox quform-field-4_16 quform-field-4_16_11\" value=\"Other\" \/><label for=\"quform_4_16_e9596d_11\" class=\"quform-option-label quform-option-label-4_16_11\"><span class=\"quform-option-text\">Other (please specify)<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-4_17 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_17\"><label class=\"quform-label-text\" for=\"quform_4_17_e9596d\">Does your child have Epileptic seizures?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-4_17\"><div class=\"quform-input quform-input-textarea quform-input-4_17 quform-cf\"><textarea id=\"quform_4_17_e9596d\" name=\"quform_4_17\" class=\"quform-field quform-field-textarea quform-field-4_17\" maxlength=\"255\"><\/textarea><\/div><p class=\"quform-description quform-description-below\">If so, please record the extent to which these are controlled and if there are any known triggers for these seizures - such as flashing\/bright lights, loud noises etc. Please note that if we believe there to be an associated risk we will remove items from The Play Therapy Pod before provision<\/p><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-4_18 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_18\"><label class=\"quform-label-text\" for=\"quform_4_18_e9596d\">Does your child have any allergies or sensitivities?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-4_18\"><div class=\"quform-input quform-input-textarea quform-input-4_18 quform-cf\"><textarea id=\"quform_4_18_e9596d\" name=\"quform_4_18\" class=\"quform-field quform-field-textarea quform-field-4_18\" maxlength=\"255\"><\/textarea><\/div><p class=\"quform-description quform-description-below\">(Please note that if we believe there to be an associated risk we will remove items from the Play Therapy Pod before provision)<\/p><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-4_19 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_19\"><label class=\"quform-label-text\" for=\"quform_4_19_e9596d\">Please tell us how you feel the requested loan of the Play Therapy Pod will support your child\u2019s development?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-4_19\"><div class=\"quform-input quform-input-textarea quform-input-4_19 quform-cf\"><textarea id=\"quform_4_19_e9596d\" name=\"quform_4_19\" class=\"quform-field quform-field-textarea quform-field-4_19\" maxlength=\"255\"><\/textarea><\/div><p class=\"quform-description quform-description-below\">Think about your child\u2019s physical, social &amp; emotional, communication and Cognitive development. <\/p><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-4_20 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_20\"><label class=\"quform-label-text\" for=\"quform_4_20_e9596d\">Which professionals have provided care to this child\/young person in the past two years? Please give their role and where possible, details of their employer and the care setting within which they deliver care; e.g. Physiotherapist, funded by NHS, delivering treatment in school.<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-4_20\"><div class=\"quform-input quform-input-textarea quform-input-4_20 quform-cf\"><textarea id=\"quform_4_20_e9596d\" name=\"quform_4_20\" class=\"quform-field quform-field-textarea quform-field-4_20\" maxlength=\"255\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-4_21 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_21\"><label class=\"quform-label-text\" id=\"quform_4_21_e9596d_label\">Does the child\/young person have an Education, Health and Care Plan (EHCP) or Statement?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-4_21\"><div class=\"quform-input quform-input-radio quform-input-4_21 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_4_21_e9596d_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_21\" id=\"quform_4_21_e9596d_1\" class=\"quform-field quform-field-radio quform-field-4_21 quform-field-4_21_1\" value=\"Yes\" \/><label for=\"quform_4_21_e9596d_1\" class=\"quform-option-label quform-option-label-4_21_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_21\" id=\"quform_4_21_e9596d_2\" class=\"quform-field quform-field-radio quform-field-4_21 quform-field-4_21_2\" value=\"No\" \/><label for=\"quform_4_21_e9596d_2\" class=\"quform-option-label quform-option-label-4_21_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_21\" id=\"quform_4_21_e9596d_4\" class=\"quform-field quform-field-radio quform-field-4_21 quform-field-4_21_4\" value=\"In Process\" \/><label for=\"quform_4_21_e9596d_4\" class=\"quform-option-label quform-option-label-4_21_4\"><span class=\"quform-option-text\">In Process<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-4_22 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_22\"><label class=\"quform-label-text\" for=\"quform_4_22_e9596d\">If \u2018Yes\u2019, when is it due its annual review:<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-4_22\"><div class=\"quform-input quform-input-textarea quform-input-4_22 quform-cf\"><textarea id=\"quform_4_22_e9596d\" name=\"quform_4_22\" class=\"quform-field quform-field-textarea quform-field-4_22\" maxlength=\"255\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-4_23 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_23\"><label class=\"quform-label-text\" for=\"quform_4_23_e9596d\">Is there any other information you would like to share to help us understand your child\/young person\u2019s needs?<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-4_23\"><div class=\"quform-input quform-input-textarea quform-input-4_23 quform-cf\"><textarea id=\"quform_4_23_e9596d\" name=\"quform_4_23\" class=\"quform-field quform-field-textarea quform-field-4_23\" maxlength=\"255\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-4_4 quform-cf quform-button-style-theme\"><div class=\"quform-button-next quform-button-next-default quform-button-next-4_4\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Next<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-25 quform-page-4_25 quform-cf quform-group-style-plain\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-4_24 quform-cf\"><div class=\"quform-spacer\">We recognise that all children\u2019s development is unique to them, and children may need toys that are better suited to their stage not their chronological age. As such we will happily accept applications for any pods that don\u2019t exceed your child\u2019s age.<br \/>\n<br \/>\nIf you need support in identifying the type of pod that would offer the most support, please don\u2019t hesitate to contact Newlife\u2019s Child and Family Support Team on 01543 468 888 option 2 or liaise with your local professional to help identify ways to use the toys in line with any existing developmental plans which you may have.<br \/>\n<br \/>\nVisual Toys - encourage visual focus, coordination and stimulation.<br \/>\nInteractive Toys - demonstrate cause and effect and encourage interactive play.<br \/>\nAuditory Toys - make noises and encourage auditory stimulation<br \/>\nTactile Toys - will stimulate touch and encourage associated motor functions<br \/>\n<br \/>\n<strong> ** <span data-teams=\"true\">Please note: The Play Therapy Pod application is based on two boxes - the second box will be sent after the first box is received back. Please select from the below in order of your preference of box types, and our teams will review availability<\/span>**<\/strong><br \/>\n<h2 class=\"quform-label quform-label-4_120\"><label id=\"quform_4_120_61248e_label\" class=\"quform-label-text\">Select one pod from each list<\/label><\/h2><br \/>\nSensory Pods \u2013 specially designed to mentally stimulate one or more of a child\u2019s senses for very early development.<br \/>\nAdventure Pods \u2013 includes themed toys, with a fun range of interactive toys available for your child to enjoy.<br \/>\nDiscovery Pods \u2013 includes visual, interactive and sensory toys, which could include instruments, light up and plushies.<br \/>\nExplorer Pods \u2013 suitable for 5 years plus, for children to explore sounds, textures and visual exploration.<\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-4_121 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-4_122\"><div class=\"quform-element quform-element-radio quform-element-4_120 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_120\"><label class=\"quform-label-text\" id=\"quform_4_120_e9596d_label\">Preference One<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-4_120\"><div class=\"quform-input quform-input-radio quform-input-4_120 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_4_120_e9596d_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_120\" id=\"quform_4_120_e9596d_1\" class=\"quform-field quform-field-radio quform-field-4_120 quform-field-4_120_1\" value=\"Sensory Pod - Sensory Play - suitable from birth\" \/><label for=\"quform_4_120_e9596d_1\" class=\"quform-option-label quform-option-label-4_120_1\"><span class=\"quform-option-text\">Sensory Pod - Sensory Play - suitable from birth<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_120\" id=\"quform_4_120_e9596d_2\" class=\"quform-field quform-field-radio quform-field-4_120 quform-field-4_120_2\" value=\"Adventure Pods - Multi-Sensory Play - suitable from 18 months\" \/><label for=\"quform_4_120_e9596d_2\" class=\"quform-option-label quform-option-label-4_120_2\"><span class=\"quform-option-text\">Adventure Pods - Multi-Sensory Play - suitable from 18 months<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_120\" id=\"quform_4_120_e9596d_11\" class=\"quform-field quform-field-radio quform-field-4_120 quform-field-4_120_11\" value=\"Discovery Pods - Discovering Vision - suitable from 3 years of age\" \/><label for=\"quform_4_120_e9596d_11\" class=\"quform-option-label quform-option-label-4_120_11\"><span class=\"quform-option-text\">Discovery Pods - Discovering Vision - suitable from 3 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_120\" id=\"quform_4_120_e9596d_10\" class=\"quform-field quform-field-radio quform-field-4_120 quform-field-4_120_10\" value=\"Discovery Pods - Discovering Sounds - suitable from 3 years of age\" \/><label for=\"quform_4_120_e9596d_10\" class=\"quform-option-label quform-option-label-4_120_10\"><span class=\"quform-option-text\">Discovery Pods - Discovering Sounds - suitable from 3 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_120\" id=\"quform_4_120_e9596d_9\" class=\"quform-field quform-field-radio quform-field-4_120 quform-field-4_120_9\" value=\"Discovery Pods - Discovering Textures - suitable from 3 years of age\" \/><label for=\"quform_4_120_e9596d_9\" class=\"quform-option-label quform-option-label-4_120_9\"><span class=\"quform-option-text\">Discovery Pods - Discovering Textures - suitable from 3 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_120\" id=\"quform_4_120_e9596d_8\" class=\"quform-field quform-field-radio quform-field-4_120 quform-field-4_120_8\" value=\"Discovery Pods - Discovering Interactions - suitable from 3 years of age\" \/><label for=\"quform_4_120_e9596d_8\" class=\"quform-option-label quform-option-label-4_120_8\"><span class=\"quform-option-text\">Discovery Pods - Discovering Interactions - suitable from 3 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_120\" id=\"quform_4_120_e9596d_7\" class=\"quform-field quform-field-radio quform-field-4_120 quform-field-4_120_7\" value=\"Discovery Pods - Discovering Communication - suitable from 3 years of age\" \/><label for=\"quform_4_120_e9596d_7\" class=\"quform-option-label quform-option-label-4_120_7\"><span class=\"quform-option-text\">Discovery Pods - Discovering Communication - suitable from 3 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_120\" id=\"quform_4_120_e9596d_6\" class=\"quform-field quform-field-radio quform-field-4_120 quform-field-4_120_6\" value=\"Explorer Pods - Exploring Vision - suitable from 5 years of age\" \/><label for=\"quform_4_120_e9596d_6\" class=\"quform-option-label quform-option-label-4_120_6\"><span class=\"quform-option-text\">Explorer Pods - Exploring Vision - suitable from 5 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_120\" id=\"quform_4_120_e9596d_5\" class=\"quform-field quform-field-radio quform-field-4_120 quform-field-4_120_5\" value=\"Explorer Pods - Exploring Sounds - suitable from 5 years of age\" \/><label for=\"quform_4_120_e9596d_5\" class=\"quform-option-label quform-option-label-4_120_5\"><span class=\"quform-option-text\">Explorer Pods - Exploring Sounds - suitable from 5 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_120\" id=\"quform_4_120_e9596d_4\" class=\"quform-field quform-field-radio quform-field-4_120 quform-field-4_120_4\" value=\"Explorer Pods - Exploring Textures - suitable from 5 years of age\" \/><label for=\"quform_4_120_e9596d_4\" class=\"quform-option-label quform-option-label-4_120_4\"><span class=\"quform-option-text\">Explorer Pods - Exploring Textures - suitable from 5 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_120\" id=\"quform_4_120_e9596d_16\" class=\"quform-field quform-field-radio quform-field-4_120 quform-field-4_120_16\" value=\"Explorer Pods - Exploring Interactions - suitable from 5 years of age\" \/><label for=\"quform_4_120_e9596d_16\" class=\"quform-option-label quform-option-label-4_120_16\"><span class=\"quform-option-text\">Explorer Pods - Exploring Interactions - suitable from 5 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_120\" id=\"quform_4_120_e9596d_15\" class=\"quform-field quform-field-radio quform-field-4_120 quform-field-4_120_15\" value=\"Explorer Pods - Exploring Communication - suitable from 5 years of age\" \/><label for=\"quform_4_120_e9596d_15\" class=\"quform-option-label quform-option-label-4_120_15\"><span class=\"quform-option-text\">Explorer Pods - Exploring Communication - suitable from 5 years of age<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-4_123\"><div class=\"quform-element quform-element-radio quform-element-4_124 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_124\"><label class=\"quform-label-text\" id=\"quform_4_124_e9596d_label\">Preference Two<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-4_124\"><div class=\"quform-input quform-input-radio quform-input-4_124 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_4_124_e9596d_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_124\" id=\"quform_4_124_e9596d_1\" class=\"quform-field quform-field-radio quform-field-4_124 quform-field-4_124_1\" value=\"Sensory Pod - Sensory Play - suitable from birth\" \/><label for=\"quform_4_124_e9596d_1\" class=\"quform-option-label quform-option-label-4_124_1\"><span class=\"quform-option-text\">Sensory Pod - Sensory Play - suitable from birth<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_124\" id=\"quform_4_124_e9596d_2\" class=\"quform-field quform-field-radio quform-field-4_124 quform-field-4_124_2\" value=\"Adventure Pods - Multi-Sensory Play - suitable from 18 months\" \/><label for=\"quform_4_124_e9596d_2\" class=\"quform-option-label quform-option-label-4_124_2\"><span class=\"quform-option-text\">Adventure Pods - Multi-Sensory Play - suitable from 18 months<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_124\" id=\"quform_4_124_e9596d_11\" class=\"quform-field quform-field-radio quform-field-4_124 quform-field-4_124_11\" value=\"Discovery Pods - Discovering Vision - suitable from 3 years of age\" \/><label for=\"quform_4_124_e9596d_11\" class=\"quform-option-label quform-option-label-4_124_11\"><span class=\"quform-option-text\">Discovery Pods - Discovering Vision - suitable from 3 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_124\" id=\"quform_4_124_e9596d_10\" class=\"quform-field quform-field-radio quform-field-4_124 quform-field-4_124_10\" value=\"Discovery Pods - Discovering Sounds - suitable from 3 years of age\" \/><label for=\"quform_4_124_e9596d_10\" class=\"quform-option-label quform-option-label-4_124_10\"><span class=\"quform-option-text\">Discovery Pods - Discovering Sounds - suitable from 3 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_124\" id=\"quform_4_124_e9596d_9\" class=\"quform-field quform-field-radio quform-field-4_124 quform-field-4_124_9\" value=\"Discovery Pods - Discovering Textures - suitable from 3 years of age\" \/><label for=\"quform_4_124_e9596d_9\" class=\"quform-option-label quform-option-label-4_124_9\"><span class=\"quform-option-text\">Discovery Pods - Discovering Textures - suitable from 3 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_124\" id=\"quform_4_124_e9596d_8\" class=\"quform-field quform-field-radio quform-field-4_124 quform-field-4_124_8\" value=\"Discovery Pods - Discovering Interactions - suitable from 3 years of age\" \/><label for=\"quform_4_124_e9596d_8\" class=\"quform-option-label quform-option-label-4_124_8\"><span class=\"quform-option-text\">Discovery Pods - Discovering Interactions - suitable from 3 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_124\" id=\"quform_4_124_e9596d_7\" class=\"quform-field quform-field-radio quform-field-4_124 quform-field-4_124_7\" value=\"Discovery Pods - Discovering Communication - suitable from 3 years of age\" \/><label for=\"quform_4_124_e9596d_7\" class=\"quform-option-label quform-option-label-4_124_7\"><span class=\"quform-option-text\">Discovery Pods - Discovering Communication - suitable from 3 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_124\" id=\"quform_4_124_e9596d_6\" class=\"quform-field quform-field-radio quform-field-4_124 quform-field-4_124_6\" value=\"Explorer Pods - Exploring Vision - suitable from 5 years of age\" \/><label for=\"quform_4_124_e9596d_6\" class=\"quform-option-label quform-option-label-4_124_6\"><span class=\"quform-option-text\">Explorer Pods - Exploring Vision - suitable from 5 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_124\" id=\"quform_4_124_e9596d_5\" class=\"quform-field quform-field-radio quform-field-4_124 quform-field-4_124_5\" value=\"Explorer Pods - Exploring Sounds - suitable from 5 years of age\" \/><label for=\"quform_4_124_e9596d_5\" class=\"quform-option-label quform-option-label-4_124_5\"><span class=\"quform-option-text\">Explorer Pods - Exploring Sounds - suitable from 5 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_124\" id=\"quform_4_124_e9596d_4\" class=\"quform-field quform-field-radio quform-field-4_124 quform-field-4_124_4\" value=\"Explorer Pods - Exploring Textures - suitable from 5 years of age\" \/><label for=\"quform_4_124_e9596d_4\" class=\"quform-option-label quform-option-label-4_124_4\"><span class=\"quform-option-text\">Explorer Pods - Exploring Textures - suitable from 5 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_124\" id=\"quform_4_124_e9596d_16\" class=\"quform-field quform-field-radio quform-field-4_124 quform-field-4_124_16\" value=\"Explorer Pods - Exploring Interactions - suitable from 5 years of age\" \/><label for=\"quform_4_124_e9596d_16\" class=\"quform-option-label quform-option-label-4_124_16\"><span class=\"quform-option-text\">Explorer Pods - Exploring Interactions - suitable from 5 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_124\" id=\"quform_4_124_e9596d_15\" class=\"quform-field quform-field-radio quform-field-4_124 quform-field-4_124_15\" value=\"Explorer Pods - Exploring Communication - suitable from 5 years of age\" \/><label for=\"quform_4_124_e9596d_15\" class=\"quform-option-label quform-option-label-4_124_15\"><span class=\"quform-option-text\">Explorer Pods - Exploring Communication - suitable from 5 years of age<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-4_133 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_133\"><label class=\"quform-label-text\" id=\"quform_4_133_e9596d_label\">Preference Three<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-4_133\"><div class=\"quform-input quform-input-radio quform-input-4_133 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_4_133_e9596d_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_133\" id=\"quform_4_133_e9596d_1\" class=\"quform-field quform-field-radio quform-field-4_133 quform-field-4_133_1\" value=\"Sensory Pod - Sensory Play - suitable from birth\" \/><label for=\"quform_4_133_e9596d_1\" class=\"quform-option-label quform-option-label-4_133_1\"><span class=\"quform-option-text\">Sensory Pod - Sensory Play - suitable from birth<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_133\" id=\"quform_4_133_e9596d_2\" class=\"quform-field quform-field-radio quform-field-4_133 quform-field-4_133_2\" value=\"Adventure Pods - Multi-Sensory Play - suitable from 18 months\" \/><label for=\"quform_4_133_e9596d_2\" class=\"quform-option-label quform-option-label-4_133_2\"><span class=\"quform-option-text\">Adventure Pods - Multi-Sensory Play - suitable from 18 months<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_133\" id=\"quform_4_133_e9596d_11\" class=\"quform-field quform-field-radio quform-field-4_133 quform-field-4_133_11\" value=\"Discovery Pods - Discovering Vision - suitable from 3 years of age\" \/><label for=\"quform_4_133_e9596d_11\" class=\"quform-option-label quform-option-label-4_133_11\"><span class=\"quform-option-text\">Discovery Pods - Discovering Vision - suitable from 3 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_133\" id=\"quform_4_133_e9596d_10\" class=\"quform-field quform-field-radio quform-field-4_133 quform-field-4_133_10\" value=\"Discovery Pods - Discovering Sounds - suitable from 3 years of age\" \/><label for=\"quform_4_133_e9596d_10\" class=\"quform-option-label quform-option-label-4_133_10\"><span class=\"quform-option-text\">Discovery Pods - Discovering Sounds - suitable from 3 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_133\" id=\"quform_4_133_e9596d_9\" class=\"quform-field quform-field-radio quform-field-4_133 quform-field-4_133_9\" value=\"Discovery Pods - Discovering Textures - suitable from 3 years of age\" \/><label for=\"quform_4_133_e9596d_9\" class=\"quform-option-label quform-option-label-4_133_9\"><span class=\"quform-option-text\">Discovery Pods - Discovering Textures - suitable from 3 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_133\" id=\"quform_4_133_e9596d_8\" class=\"quform-field quform-field-radio quform-field-4_133 quform-field-4_133_8\" value=\"Discovery Pods - Discovering Interactions - suitable from 3 years of age\" \/><label for=\"quform_4_133_e9596d_8\" class=\"quform-option-label quform-option-label-4_133_8\"><span class=\"quform-option-text\">Discovery Pods - Discovering Interactions - suitable from 3 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_133\" id=\"quform_4_133_e9596d_7\" class=\"quform-field quform-field-radio quform-field-4_133 quform-field-4_133_7\" value=\"Discovery Pods - Discovering Communication - suitable from 3 years of age\" \/><label for=\"quform_4_133_e9596d_7\" class=\"quform-option-label quform-option-label-4_133_7\"><span class=\"quform-option-text\">Discovery Pods - Discovering Communication - suitable from 3 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_133\" id=\"quform_4_133_e9596d_6\" class=\"quform-field quform-field-radio quform-field-4_133 quform-field-4_133_6\" value=\"Explorer Pods - Exploring Vision - suitable from 5 years of age\" \/><label for=\"quform_4_133_e9596d_6\" class=\"quform-option-label quform-option-label-4_133_6\"><span class=\"quform-option-text\">Explorer Pods - Exploring Vision - suitable from 5 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_133\" id=\"quform_4_133_e9596d_5\" class=\"quform-field quform-field-radio quform-field-4_133 quform-field-4_133_5\" value=\"Explorer Pods - Exploring Sounds - suitable from 5 years of age\" \/><label for=\"quform_4_133_e9596d_5\" class=\"quform-option-label quform-option-label-4_133_5\"><span class=\"quform-option-text\">Explorer Pods - Exploring Sounds - suitable from 5 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_133\" id=\"quform_4_133_e9596d_4\" class=\"quform-field quform-field-radio quform-field-4_133 quform-field-4_133_4\" value=\"Explorer Pods - Exploring Textures - suitable from 5 years of age\" \/><label for=\"quform_4_133_e9596d_4\" class=\"quform-option-label quform-option-label-4_133_4\"><span class=\"quform-option-text\">Explorer Pods - Exploring Textures - suitable from 5 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_133\" id=\"quform_4_133_e9596d_16\" class=\"quform-field quform-field-radio quform-field-4_133 quform-field-4_133_16\" value=\"Explorer Pods - Exploring Interactions - suitable from 5 years of age\" \/><label for=\"quform_4_133_e9596d_16\" class=\"quform-option-label quform-option-label-4_133_16\"><span class=\"quform-option-text\">Explorer Pods - Exploring Interactions - suitable from 5 years of age<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_133\" id=\"quform_4_133_e9596d_15\" class=\"quform-field quform-field-radio quform-field-4_133 quform-field-4_133_15\" value=\"Explorer Pods - Exploring Communication - suitable from 5 years of age\" \/><label for=\"quform_4_133_e9596d_15\" class=\"quform-option-label quform-option-label-4_133_15\"><span class=\"quform-option-text\">Explorer Pods - Exploring Communication - suitable from 5 years of age<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-4_131 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_131\"><label class=\"quform-label-text\" id=\"quform_4_131_e9596d_label\">I confirm that the pods I have selected are age appropriate for my child:<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-4_131\"><div class=\"quform-input quform-input-checkbox quform-input-4_131 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_4_131_e9596d_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_131[]\" id=\"quform_4_131_e9596d_1\" class=\"quform-field quform-field-checkbox quform-field-4_131 quform-field-4_131_1\" value=\"Yes, my child is the correct age for these toys\" \/><label for=\"quform_4_131_e9596d_1\" class=\"quform-option-label quform-option-label-4_131_1\"><span class=\"quform-option-text\">Yes, my child is the correct age for these toys<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_131[]\" id=\"quform_4_131_e9596d_2\" class=\"quform-field quform-field-checkbox quform-field-4_131 quform-field-4_131_2\" value=\"No - please select a different pod or application may be denied\" \/><label for=\"quform_4_131_e9596d_2\" class=\"quform-option-label quform-option-label-4_131_2\"><span class=\"quform-option-text\">No - please select a different pod or application may be denied<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-4_32 quform-cf\"><div class=\"quform-spacer\"><strong>Child Demographic Information.<\/strong>\n\nPlease tick the box that you feel is most appropriate:<\/div><\/div><div class=\"quform-element quform-element-radio quform-element-4_31 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_31\"><label class=\"quform-label-text\" id=\"quform_4_31_e9596d_label\">Background<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-4_31\"><div class=\"quform-input quform-input-radio quform-input-4_31 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_4_31_e9596d_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_31\" id=\"quform_4_31_e9596d_2\" class=\"quform-field quform-field-radio quform-field-4_31 quform-field-4_31_2\" value=\"White - English\/Scottish\/Welsh\/NI\" \/><label for=\"quform_4_31_e9596d_2\" class=\"quform-option-label quform-option-label-4_31_2\"><span class=\"quform-option-text\">White - English\/Scottish\/Welsh\/NI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_31\" id=\"quform_4_31_e9596d_3\" class=\"quform-field quform-field-radio quform-field-4_31 quform-field-4_31_3\" value=\"White - Irish\" \/><label for=\"quform_4_31_e9596d_3\" class=\"quform-option-label quform-option-label-4_31_3\"><span class=\"quform-option-text\">White - Irish<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_31\" id=\"quform_4_31_e9596d_4\" class=\"quform-field quform-field-radio quform-field-4_31 quform-field-4_31_4\" value=\"White - Gypsy or Irish traveller\" \/><label for=\"quform_4_31_e9596d_4\" class=\"quform-option-label quform-option-label-4_31_4\"><span class=\"quform-option-text\">White - Gypsy or Irish traveller<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_31\" id=\"quform_4_31_e9596d_5\" class=\"quform-field quform-field-radio quform-field-4_31 quform-field-4_31_5\" value=\"Any other white background\" \/><label for=\"quform_4_31_e9596d_5\" class=\"quform-option-label quform-option-label-4_31_5\"><span class=\"quform-option-text\">Any other white background<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_31\" id=\"quform_4_31_e9596d_10\" class=\"quform-field quform-field-radio quform-field-4_31 quform-field-4_31_10\" value=\"Asian\/Asian UK - Indian\" \/><label for=\"quform_4_31_e9596d_10\" class=\"quform-option-label quform-option-label-4_31_10\"><span class=\"quform-option-text\">Asian\/Asian UK - Indian<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_31\" id=\"quform_4_31_e9596d_11\" class=\"quform-field quform-field-radio quform-field-4_31 quform-field-4_31_11\" value=\"Asian\/Asian UK - Pakistani\" \/><label for=\"quform_4_31_e9596d_11\" class=\"quform-option-label quform-option-label-4_31_11\"><span class=\"quform-option-text\">Asian\/Asian UK - Pakistani<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_31\" id=\"quform_4_31_e9596d_12\" class=\"quform-field quform-field-radio quform-field-4_31 quform-field-4_31_12\" value=\"Asian\/Asian UK - Bangladeshi\" \/><label for=\"quform_4_31_e9596d_12\" class=\"quform-option-label quform-option-label-4_31_12\"><span class=\"quform-option-text\">Asian\/Asian UK - Bangladeshi<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_31\" id=\"quform_4_31_e9596d_13\" class=\"quform-field quform-field-radio quform-field-4_31 quform-field-4_31_13\" value=\"Asian\/Asian UK - Chinese\" \/><label for=\"quform_4_31_e9596d_13\" class=\"quform-option-label quform-option-label-4_31_13\"><span class=\"quform-option-text\">Asian\/Asian UK - Chinese<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_31\" id=\"quform_4_31_e9596d_14\" class=\"quform-field quform-field-radio quform-field-4_31 quform-field-4_31_14\" value=\"Any other Asian background\" \/><label for=\"quform_4_31_e9596d_14\" class=\"quform-option-label quform-option-label-4_31_14\"><span class=\"quform-option-text\">Any other Asian background<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_31\" id=\"quform_4_31_e9596d_15\" class=\"quform-field quform-field-radio quform-field-4_31 quform-field-4_31_15\" value=\"Mixed ethnic background\" \/><label for=\"quform_4_31_e9596d_15\" class=\"quform-option-label quform-option-label-4_31_15\"><span class=\"quform-option-text\">Mixed ethnic background<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_31\" id=\"quform_4_31_e9596d_16\" class=\"quform-field quform-field-radio quform-field-4_31 quform-field-4_31_16\" value=\"Black\/Black UK - African\" \/><label for=\"quform_4_31_e9596d_16\" class=\"quform-option-label quform-option-label-4_31_16\"><span class=\"quform-option-text\">Black\/Black UK - African<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_31\" id=\"quform_4_31_e9596d_17\" class=\"quform-field quform-field-radio quform-field-4_31 quform-field-4_31_17\" value=\"Black\/Black UK - Caribbean\" \/><label for=\"quform_4_31_e9596d_17\" class=\"quform-option-label quform-option-label-4_31_17\"><span class=\"quform-option-text\">Black\/Black UK - Caribbean<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_31\" id=\"quform_4_31_e9596d_18\" class=\"quform-field quform-field-radio quform-field-4_31 quform-field-4_31_18\" value=\"Any other Black\/African\/ Caribbean background\" \/><label for=\"quform_4_31_e9596d_18\" class=\"quform-option-label quform-option-label-4_31_18\"><span class=\"quform-option-text\">Any other Black\/African\/ Caribbean background<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_31\" id=\"quform_4_31_e9596d_19\" class=\"quform-field quform-field-radio quform-field-4_31 quform-field-4_31_19\" value=\"Arab\" \/><label for=\"quform_4_31_e9596d_19\" class=\"quform-option-label quform-option-label-4_31_19\"><span class=\"quform-option-text\">Arab<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_31\" id=\"quform_4_31_e9596d_20\" class=\"quform-field quform-field-radio quform-field-4_31 quform-field-4_31_20\" value=\"Any other ethnic group\" \/><label for=\"quform_4_31_e9596d_20\" class=\"quform-option-label quform-option-label-4_31_20\"><span class=\"quform-option-text\">Any other ethnic group<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_31\" id=\"quform_4_31_e9596d_21\" class=\"quform-field quform-field-radio quform-field-4_31 quform-field-4_31_21\" value=\"Prefer not to say\" \/><label for=\"quform_4_31_e9596d_21\" class=\"quform-option-label quform-option-label-4_31_21\"><span class=\"quform-option-text\">Prefer not to say<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-4_26 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-4_26\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Back<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-4_26\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Next<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-101 quform-page-4_101 quform-cf quform-group-style-plain\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-4_103 quform-cf\"><div class=\"quform-spacer\"><h1>Parent\/Primary Carer details<\/h1><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-4_40 quform-cf quform-labels-left quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_40\"><label class=\"quform-label-text\" id=\"quform_4_40_e9596d_label\">Title<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-4_40\"><div class=\"quform-input quform-input-radio quform-input-4_40 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_4_40_e9596d_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_40\" id=\"quform_4_40_e9596d_1\" class=\"quform-field quform-field-radio quform-field-4_40 quform-field-4_40_1\" value=\"Mr\" \/><label for=\"quform_4_40_e9596d_1\" class=\"quform-option-label quform-option-label-4_40_1\"><span class=\"quform-option-text\">Mr<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_40\" id=\"quform_4_40_e9596d_2\" class=\"quform-field quform-field-radio quform-field-4_40 quform-field-4_40_2\" value=\"Mrs\" \/><label for=\"quform_4_40_e9596d_2\" class=\"quform-option-label quform-option-label-4_40_2\"><span class=\"quform-option-text\">Mrs<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_40\" id=\"quform_4_40_e9596d_3\" class=\"quform-field quform-field-radio quform-field-4_40 quform-field-4_40_3\" value=\"Ms\" \/><label for=\"quform_4_40_e9596d_3\" class=\"quform-option-label quform-option-label-4_40_3\"><span class=\"quform-option-text\">Ms<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_40\" id=\"quform_4_40_e9596d_4\" class=\"quform-field quform-field-radio quform-field-4_40 quform-field-4_40_4\" value=\"Dr\" \/><label for=\"quform_4_40_e9596d_4\" class=\"quform-option-label quform-option-label-4_40_4\"><span class=\"quform-option-text\">Dr<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-name quform-element-4_41 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_41\"><label class=\"quform-label-text\" id=\"quform_4_41_e9596d_label\">Name<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-name quform-inner-4_41\"><div class=\"quform-input quform-input-name quform-input-4_41 quform-cf\"><div class=\"quform-element-row quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element-column\"><div class=\"quform-element quform-element-text quform-element-4_41_2 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-text quform-inner-4_41_2\"><div class=\"quform-input quform-input-text quform-input-4_41_2 quform-cf\"><input type=\"text\" id=\"quform_4_41_2_e9596d\" name=\"quform_4_41[2]\" class=\"quform-field quform-field-text quform-field-4_41_2\" aria-labelledby=\"quform_4_41_e9596d_label quform_4_41_2_e9596d_sub_label_below\" \/><\/div><label id=\"quform_4_41_2_e9596d_sub_label_below\" class=\"quform-sub-label quform-sub-label-below\">First<\/label><\/div><\/div><\/div><\/div><div class=\"quform-element-column\"><div class=\"quform-element quform-element-text quform-element-4_41_4 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-text quform-inner-4_41_4\"><div class=\"quform-input quform-input-text quform-input-4_41_4 quform-cf\"><input type=\"text\" id=\"quform_4_41_4_e9596d\" name=\"quform_4_41[4]\" class=\"quform-field quform-field-text quform-field-4_41_4\" aria-labelledby=\"quform_4_41_e9596d_label quform_4_41_4_e9596d_sub_label_below\" \/><\/div><label id=\"quform_4_41_4_e9596d_sub_label_below\" class=\"quform-sub-label quform-sub-label-below\">Last<\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-4_44 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-4_45\"><div class=\"quform-element quform-element-text quform-element-4_43 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_43\"><label class=\"quform-label-text\" for=\"quform_4_43_e9596d\">Address:<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-4_43\"><div class=\"quform-input quform-input-text quform-input-4_43 quform-cf\"><input type=\"text\" id=\"quform_4_43_e9596d\" name=\"quform_4_43\" class=\"quform-field quform-field-text quform-field-4_43\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-4_46\"><div class=\"quform-element quform-element-text quform-element-4_42 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_42\"><label class=\"quform-label-text\" for=\"quform_4_42_e9596d\">Postcode<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-4_42\"><div class=\"quform-input quform-input-text quform-input-4_42 quform-cf\"><input type=\"text\" id=\"quform_4_42_e9596d\" name=\"quform_4_42\" class=\"quform-field quform-field-text quform-field-4_42\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-4_49 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-4_50\"><div class=\"quform-element quform-element-text quform-element-4_47 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_47\"><label class=\"quform-label-text\" for=\"quform_4_47_e9596d\">Tel. No.<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-4_47\"><div class=\"quform-input quform-input-text quform-input-4_47 quform-cf\"><input type=\"text\" id=\"quform_4_47_e9596d\" name=\"quform_4_47\" class=\"quform-field quform-field-text quform-field-4_47\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-4_51\"><div class=\"quform-element quform-element-text quform-element-4_48 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_48\"><label class=\"quform-label-text\" for=\"quform_4_48_e9596d\">Mobile<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-4_48\"><div class=\"quform-input quform-input-text quform-input-4_48 quform-cf\"><input type=\"text\" id=\"quform_4_48_e9596d\" name=\"quform_4_48\" class=\"quform-field quform-field-text quform-field-4_48\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-email quform-element-4_129 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_129\"><label class=\"quform-label-text\" for=\"quform_4_129_e9596d\">Email<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-email quform-inner-4_129\"><div class=\"quform-input quform-input-email quform-input-4_129 quform-cf\"><input type=\"email\" id=\"quform_4_129_e9596d\" name=\"quform_4_129\" class=\"quform-field quform-field-email quform-field-4_129\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-4_53 quform-cf quform-labels-left quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_53\"><label class=\"quform-label-text\" id=\"quform_4_53_e9596d_label\">Who is filling out this application form?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-4_53\"><div class=\"quform-input quform-input-radio quform-input-4_53 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_4_53_e9596d_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_53\" id=\"quform_4_53_e9596d_1\" class=\"quform-field quform-field-radio quform-field-4_53 quform-field-4_53_1\" value=\"Parent\/Carer\" \/><label for=\"quform_4_53_e9596d_1\" class=\"quform-option-label quform-option-label-4_53_1\"><span class=\"quform-option-text\">Parent\/Carer<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_53\" id=\"quform_4_53_e9596d_2\" class=\"quform-field quform-field-radio quform-field-4_53 quform-field-4_53_2\" value=\"Medical Professional\" \/><label for=\"quform_4_53_e9596d_2\" class=\"quform-option-label quform-option-label-4_53_2\"><span class=\"quform-option-text\">Medical Professional<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-4_132 quform-cf quform-labels-left quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_132\"><label class=\"quform-label-text\" id=\"quform_4_132_e9596d_label\">Have you used our services before?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-4_132\"><div class=\"quform-input quform-input-radio quform-input-4_132 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_4_132_e9596d_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_132\" id=\"quform_4_132_e9596d_1\" class=\"quform-field quform-field-radio quform-field-4_132 quform-field-4_132_1\" value=\"Yes\" \/><label for=\"quform_4_132_e9596d_1\" class=\"quform-option-label quform-option-label-4_132_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_132\" id=\"quform_4_132_e9596d_2\" class=\"quform-field quform-field-radio quform-field-4_132 quform-field-4_132_2\" value=\"No\" \/><label for=\"quform_4_132_e9596d_2\" class=\"quform-option-label quform-option-label-4_132_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-4_54 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_54\"><label class=\"quform-label-text\" for=\"quform_4_54_e9596d\">How did you hear about our services?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-4_54\"><div class=\"quform-input quform-input-textarea quform-input-4_54 quform-cf\"><textarea id=\"quform_4_54_e9596d\" name=\"quform_4_54\" class=\"quform-field quform-field-textarea quform-field-4_54\" maxlength=\"255\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-4_55 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_55\"><label class=\"quform-label-text\" for=\"quform_4_55_e9596d\">Do you have any health conditions\/disabilities or mental health difficulties? Please provide as much detail as possible as Newlife\u2019s Child and Family Support Team consider the difference that equipment provision makes, to the whole family. <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-4_55\"><div class=\"quform-input quform-input-textarea quform-input-4_55 quform-cf\"><textarea id=\"quform_4_55_e9596d\" name=\"quform_4_55\" class=\"quform-field quform-field-textarea quform-field-4_55\" maxlength=\"255\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-4_56 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_56\"><label class=\"quform-label-text\" id=\"quform_4_56_e9596d_label\">Are there any other children or siblings of the child\/young person, living in the same home?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-4_56\"><div class=\"quform-input quform-input-radio quform-input-4_56 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_4_56_e9596d_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_56\" id=\"quform_4_56_e9596d_1\" class=\"quform-field quform-field-radio quform-field-4_56 quform-field-4_56_1\" value=\"Yes\" \/><label for=\"quform_4_56_e9596d_1\" class=\"quform-option-label quform-option-label-4_56_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_56\" id=\"quform_4_56_e9596d_2\" class=\"quform-field quform-field-radio quform-field-4_56 quform-field-4_56_2\" value=\"No\" \/><label for=\"quform_4_56_e9596d_2\" class=\"quform-option-label quform-option-label-4_56_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-4_57 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_57\"><label class=\"quform-label-text\" for=\"quform_4_57_e9596d\">If so, please give their gender, age and state if they have any significant health conditions\/disabilities:<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-4_57\"><div class=\"quform-input quform-input-textarea quform-input-4_57 quform-cf\"><textarea id=\"quform_4_57_e9596d\" name=\"quform_4_57\" class=\"quform-field quform-field-textarea quform-field-4_57\" maxlength=\"255\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-4_58 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_58\"><label class=\"quform-label-text\" id=\"quform_4_58_e9596d_label\">Are the toys requested for use at a different address than the child\u2019s home?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-4_58\"><div class=\"quform-input quform-input-radio quform-input-4_58 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_4_58_e9596d_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_58\" id=\"quform_4_58_e9596d_1\" class=\"quform-field quform-field-radio quform-field-4_58 quform-field-4_58_1\" value=\"Yes\" \/><label for=\"quform_4_58_e9596d_1\" class=\"quform-option-label quform-option-label-4_58_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_58\" id=\"quform_4_58_e9596d_2\" class=\"quform-field quform-field-radio quform-field-4_58 quform-field-4_58_2\" value=\"No\" \/><label for=\"quform_4_58_e9596d_2\" class=\"quform-option-label quform-option-label-4_58_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-4_59 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_59\"><label class=\"quform-label-text\" for=\"quform_4_59_e9596d\">If \u2018Yes\u2019 please provide the address and identify if you would prefer the Play Therapy Pod to be delivered to this address<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-4_59\"><div class=\"quform-input quform-input-textarea quform-input-4_59 quform-cf\"><textarea id=\"quform_4_59_e9596d\" name=\"quform_4_59\" class=\"quform-field quform-field-textarea quform-field-4_59\" maxlength=\"255\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-4_125 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_125\"><label class=\"quform-label-text\" id=\"quform_4_125_e9596d_label\">Do you receive any of the following benefits (tick any that apply)? *<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-4_125\"><div class=\"quform-input quform-input-checkbox quform-input-4_125 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_4_125_e9596d_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_125[]\" id=\"quform_4_125_e9596d_1\" class=\"quform-field quform-field-checkbox quform-field-4_125 quform-field-4_125_1\" value=\"Universal Credit (This may include, income support, housing benefit, ESA, JSA, Working Tax Credit, Child Tax Credit)\" \/><label for=\"quform_4_125_e9596d_1\" class=\"quform-option-label quform-option-label-4_125_1\"><span class=\"quform-option-text\">Universal Credit (This may include, income support, housing benefit, ESA, JSA, Working Tax Credit, Child Tax Credit)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_125[]\" id=\"quform_4_125_e9596d_2\" class=\"quform-field quform-field-checkbox quform-field-4_125 quform-field-4_125_2\" value=\"Personal Independence Payment\/ Disability Living Allowance\" \/><label for=\"quform_4_125_e9596d_2\" class=\"quform-option-label quform-option-label-4_125_2\"><span class=\"quform-option-text\">Personal Independence Payment\/ Disability Living Allowance<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_125[]\" id=\"quform_4_125_e9596d_3\" class=\"quform-field quform-field-checkbox quform-field-4_125 quform-field-4_125_3\" value=\"Council Tax Relief \" \/><label for=\"quform_4_125_e9596d_3\" class=\"quform-option-label quform-option-label-4_125_3\"><span class=\"quform-option-text\">Council Tax Relief <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_125[]\" id=\"quform_4_125_e9596d_4\" class=\"quform-field quform-field-checkbox quform-field-4_125 quform-field-4_125_4\" value=\"Pension Credit\" \/><label for=\"quform_4_125_e9596d_4\" class=\"quform-option-label quform-option-label-4_125_4\"><span class=\"quform-option-text\">Pension Credit<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_125[]\" id=\"quform_4_125_e9596d_5\" class=\"quform-field quform-field-checkbox quform-field-4_125 quform-field-4_125_5\" value=\"Blue Badge \" \/><label for=\"quform_4_125_e9596d_5\" class=\"quform-option-label quform-option-label-4_125_5\"><span class=\"quform-option-text\">Blue Badge <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_125[]\" id=\"quform_4_125_e9596d_6\" class=\"quform-field quform-field-checkbox quform-field-4_125 quform-field-4_125_6\" value=\"Lease of vehicle through Motability\" \/><label for=\"quform_4_125_e9596d_6\" class=\"quform-option-label quform-option-label-4_125_6\"><span class=\"quform-option-text\">Lease of vehicle through Motability<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_125[]\" id=\"quform_4_125_e9596d_7\" class=\"quform-field quform-field-checkbox quform-field-4_125 quform-field-4_125_7\" value=\"Not applicable\" \/><label for=\"quform_4_125_e9596d_7\" class=\"quform-option-label quform-option-label-4_125_7\"><span class=\"quform-option-text\">Not applicable<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-4_60 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_60\"><label class=\"quform-label-text\" id=\"quform_4_60_e9596d_label\">Have you completed this application form with a professional?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-4_60\"><div class=\"quform-input quform-input-radio quform-input-4_60 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_4_60_e9596d_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_60\" id=\"quform_4_60_e9596d_1\" class=\"quform-field quform-field-radio quform-field-4_60 quform-field-4_60_1\" value=\"Yes\" \/><label for=\"quform_4_60_e9596d_1\" class=\"quform-option-label quform-option-label-4_60_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_60\" id=\"quform_4_60_e9596d_2\" class=\"quform-field quform-field-radio quform-field-4_60 quform-field-4_60_2\" value=\"No\" \/><label for=\"quform_4_60_e9596d_2\" class=\"quform-option-label quform-option-label-4_60_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-4_102 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-4_102\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Back<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-4_102\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Next<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-104 quform-page-4_104 quform-cf quform-group-style-plain\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-4_61 quform-cf\"><div class=\"quform-spacer\"><h3>Professional Details<\/h3><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-4_64 quform-3-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-4_65\"><div class=\"quform-element quform-element-text quform-element-4_68 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_68\"><label class=\"quform-label-text\" for=\"quform_4_68_e9596d\">First name:<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-4_68\"><div class=\"quform-input quform-input-text quform-input-4_68 quform-cf\"><input type=\"text\" id=\"quform_4_68_e9596d\" name=\"quform_4_68\" class=\"quform-field quform-field-text quform-field-4_68\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-4_66\"><div class=\"quform-element quform-element-text quform-element-4_69 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_69\"><label class=\"quform-label-text\" for=\"quform_4_69_e9596d\">Surname:<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-4_69\"><div class=\"quform-input quform-input-text quform-input-4_69 quform-cf\"><input type=\"text\" id=\"quform_4_69_e9596d\" name=\"quform_4_69\" class=\"quform-field quform-field-text quform-field-4_69\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-4_67\"><div class=\"quform-element quform-element-text quform-element-4_70 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_70\"><label class=\"quform-label-text\" for=\"quform_4_70_e9596d\">Job Title<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-4_70\"><div class=\"quform-input quform-input-text quform-input-4_70 quform-cf\"><input type=\"text\" id=\"quform_4_70_e9596d\" name=\"quform_4_70\" class=\"quform-field quform-field-text quform-field-4_70\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-4_106 quform-3-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-4_107\"><div class=\"quform-element quform-element-text quform-element-4_110 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_110\"><label class=\"quform-label-text\" for=\"quform_4_110_e9596d\">Address<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-4_110\"><div class=\"quform-input quform-input-text quform-input-4_110 quform-cf\"><input type=\"text\" id=\"quform_4_110_e9596d\" name=\"quform_4_110\" class=\"quform-field quform-field-text quform-field-4_110\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-4_109\"><div class=\"quform-element quform-element-text quform-element-4_111 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_111\"><label class=\"quform-label-text\" for=\"quform_4_111_e9596d\">Postcode<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-4_111\"><div class=\"quform-input quform-input-text quform-input-4_111 quform-cf\"><input type=\"text\" id=\"quform_4_111_e9596d\" name=\"quform_4_111\" class=\"quform-field quform-field-text quform-field-4_111\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-4_108\"><div class=\"quform-element quform-element-text quform-element-4_112 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_112\"><label class=\"quform-label-text\" for=\"quform_4_112_e9596d\">Work Tel No.<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-4_112\"><div class=\"quform-input quform-input-text quform-input-4_112 quform-cf\"><input type=\"text\" id=\"quform_4_112_e9596d\" name=\"quform_4_112\" class=\"quform-field quform-field-text quform-field-4_112\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-4_79 quform-3-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-4_80\"><div class=\"quform-element quform-element-text quform-element-4_81 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_81\"><label class=\"quform-label-text\" for=\"quform_4_81_e9596d\">Mobile:<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-4_81\"><div class=\"quform-input quform-input-text quform-input-4_81 quform-cf\"><input type=\"text\" id=\"quform_4_81_e9596d\" name=\"quform_4_81\" class=\"quform-field quform-field-text quform-field-4_81\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-4_82\"><div class=\"quform-element quform-element-text quform-element-4_83 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_83\"><label class=\"quform-label-text\" for=\"quform_4_83_e9596d\">Email<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-4_83\"><div class=\"quform-input quform-input-text quform-input-4_83 quform-cf\"><input type=\"text\" id=\"quform_4_83_e9596d\" name=\"quform_4_83\" class=\"quform-field quform-field-text quform-field-4_83\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-4_84\"><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-4_105 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-4_105\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Back<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-4_105\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Next<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-86 quform-page-4_86 quform-cf quform-group-style-plain quform-last-page\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-4_88 quform-cf\"><div class=\"quform-spacer\"><h3><u>Terms and Conditions<\/u><\/h3>\n<ol>\n \t<li>All the information given in this application process is up to date to the best of your knowledge.<\/li>\n \t<li>Newlife is a Charity and while we will try to help as many families as possible there may be occasions that we are unable to help.<\/li>\n \t<li>Please remember that the equipment provided should be used for the intended child\/young person.<\/li>\n \t<li>The Equipment may be provided to you as a charitable act. We will therefore only be responsible for any loss or damage that you suffer in connection with this agreement, to the extent that we are able to claim for such loss or damage under our insurance.<\/li>\n \t<li>Following delivery of Play Therapy Pod, we will contact you to gather feedback on the service you received and the difference made by the use of the toys.<\/li>\n \t<li>Do not use the items within the Play Therapy Pod until you have read all the instructions included in the pod and to agree to always follow all instructions and recommendations provided to you by us, the manufacturer or supplier of the items included in the Pod. The information supplied covers health and safety aspects and guidance for looking after the contents during the loan period.<\/li>\n \t<li>You will be responsible for the Pod for 12 weeks, once loaned to you by Newlife. Within this 12 week period, if you no longer need the Pod, we need you to tell us as soon as possible so we can arrange for it to be collected from your home. This will usually be within three working days, but we will agree a suitable date for this collection with you. If you need it for longer than 12 weeks we will liaise with you regarding an extension or change of provision.<\/li>\n \t<li>Tell us if the Pod and its contents become unsuitable for your child to use, due to changes in need or circumstances.<\/li>\n \t<li>The Play Therapy Pod and its contents remains the property of Newlife, and we retain the right to recall the pod and its contents. This notice will normally be given in writing.<\/li>\n \t<li>Take all reasonable steps to ensure that the Pod and contents are properly looked after. If the contents are lost, stolen or damaged whilst in your possession then you must let us know as soon as possible. We will arrange for the Pod and contents to be inspected and if possible replaced.<\/li>\n \t<li>Following the loan of a play therapy pod, we will arrange collection on a date and time that is convenient for you. If we are unable to arrange this and as a result the Play Theory pod is not returned., All further loans within the your application will be terminated .<\/li>\n<\/ol><\/div><\/div><div class=\"quform-element quform-element-html quform-element-4_89 quform-cf\"><div class=\"quform-spacer\"><h3>Family Declaration<\/h3><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-4_90 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_90\"><label class=\"quform-label-text\" id=\"quform_4_90_e9596d_label\">Do you agree to Newlife providing the child\/young person\u2019s basic information to help demonstrate how specialist equipment can change young lives, help promote our services to other families, encourage fundraising and donations as well as help raise general awareness of the charity? This will be information such as name, age, county, description of their condition and the difference the equipment will make. <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-4_90\"><div class=\"quform-input quform-input-radio quform-input-4_90 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_4_90_e9596d_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_90\" id=\"quform_4_90_e9596d_1\" class=\"quform-field quform-field-radio quform-field-4_90 quform-field-4_90_1\" value=\"Yes\" \/><label for=\"quform_4_90_e9596d_1\" class=\"quform-option-label quform-option-label-4_90_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_90\" id=\"quform_4_90_e9596d_2\" class=\"quform-field quform-field-radio quform-field-4_90 quform-field-4_90_2\" value=\"No\" \/><label for=\"quform_4_90_e9596d_2\" class=\"quform-option-label quform-option-label-4_90_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-4_91 quform-cf\"><div class=\"quform-spacer\">It\u2019s important, that we can share some basic information. This is common with most charities who are highly dependent on the public to help them meet the needs of children and their families.<\/div><\/div><div class=\"quform-element quform-element-radio quform-element-4_92 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_92\"><label class=\"quform-label-text\" id=\"quform_4_92_e9596d_label\">Do you agree to provide a photo of the child\/young person that could be used to highlight how equipment helps which would be shared with donors, supporters and families? <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-4_92\"><div class=\"quform-input quform-input-radio quform-input-4_92 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_4_92_e9596d_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_92\" id=\"quform_4_92_e9596d_1\" class=\"quform-field quform-field-radio quform-field-4_92 quform-field-4_92_1\" value=\"Yes\" \/><label for=\"quform_4_92_e9596d_1\" class=\"quform-option-label quform-option-label-4_92_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_92\" id=\"quform_4_92_e9596d_2\" class=\"quform-field quform-field-radio quform-field-4_92 quform-field-4_92_2\" value=\"No\" \/><label for=\"quform_4_92_e9596d_2\" class=\"quform-option-label quform-option-label-4_92_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-4_93 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_93\"><label class=\"quform-label-text\" id=\"quform_4_93_e9596d_label\">As a charity, it is necessary to raise funds to be able to continue our service to children and families. Are you happy to receive updates and news including other ways to get involved from our fundraising team? <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-4_93\"><div class=\"quform-input quform-input-radio quform-input-4_93 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_4_93_e9596d_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_93\" id=\"quform_4_93_e9596d_1\" class=\"quform-field quform-field-radio quform-field-4_93 quform-field-4_93_1\" value=\"Yes\" \/><label for=\"quform_4_93_e9596d_1\" class=\"quform-option-label quform-option-label-4_93_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_93\" id=\"quform_4_93_e9596d_2\" class=\"quform-field quform-field-radio quform-field-4_93 quform-field-4_93_2\" value=\"No\" \/><label for=\"quform_4_93_e9596d_2\" class=\"quform-option-label quform-option-label-4_93_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-4_94 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_94\"><label class=\"quform-label-text\" id=\"quform_4_94_e9596d_label\">Would you be interested in speaking to our volunteering team about wider opportunities to support the charity? <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-4_94\"><div class=\"quform-input quform-input-radio quform-input-4_94 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_4_94_e9596d_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_94\" id=\"quform_4_94_e9596d_1\" class=\"quform-field quform-field-radio quform-field-4_94 quform-field-4_94_1\" value=\"Yes\" \/><label for=\"quform_4_94_e9596d_1\" class=\"quform-option-label quform-option-label-4_94_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_94\" id=\"quform_4_94_e9596d_2\" class=\"quform-field quform-field-radio quform-field-4_94 quform-field-4_94_2\" value=\"No\" \/><label for=\"quform_4_94_e9596d_2\" class=\"quform-option-label quform-option-label-4_94_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-4_95 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_95\"><label class=\"quform-label-text\" id=\"quform_4_95_e9596d_label\">Do you consent to allow Newlife to share your personal data with third parties to help Newlife analyse what we do?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-4_95\"><div class=\"quform-input quform-input-radio quform-input-4_95 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_4_95_e9596d_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_95\" id=\"quform_4_95_e9596d_1\" class=\"quform-field quform-field-radio quform-field-4_95 quform-field-4_95_1\" value=\"Yes\" \/><label for=\"quform_4_95_e9596d_1\" class=\"quform-option-label quform-option-label-4_95_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_4_95\" id=\"quform_4_95_e9596d_2\" class=\"quform-field quform-field-radio quform-field-4_95 quform-field-4_95_2\" value=\"No\" \/><label for=\"quform_4_95_e9596d_2\" class=\"quform-option-label quform-option-label-4_95_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-4_96 quform-cf\"><div class=\"quform-spacer\">In these cases Newlife will remain the Data Controller but will simply share your data for the purpose of data analysis only. In all cases we will use a non-disclosure agreement to ensure that the third party does not misuse any data provided.<\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-4_113 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_113\"><label class=\"quform-label-text\" id=\"quform_4_113_e9596d_label\">For all the questions above where we ask you if you are happy to be contacted by a Newlife team, other than the Child and Family Support Team, please specify your preferred method of contact (please tick all that apply):<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-4_113\"><div class=\"quform-input quform-input-checkbox quform-input-4_113 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_4_113_e9596d_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_113[]\" id=\"quform_4_113_e9596d_1\" class=\"quform-field quform-field-checkbox quform-field-4_113 quform-field-4_113_1\" value=\"By post \" \/><label for=\"quform_4_113_e9596d_1\" class=\"quform-option-label quform-option-label-4_113_1\"><span class=\"quform-option-text\">By post <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_113[]\" id=\"quform_4_113_e9596d_2\" class=\"quform-field quform-field-checkbox quform-field-4_113 quform-field-4_113_2\" value=\"By email\" \/><label for=\"quform_4_113_e9596d_2\" class=\"quform-option-label quform-option-label-4_113_2\"><span class=\"quform-option-text\">By email<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_113[]\" id=\"quform_4_113_e9596d_3\" class=\"quform-field quform-field-checkbox quform-field-4_113 quform-field-4_113_3\" value=\"By phone\" \/><label for=\"quform_4_113_e9596d_3\" class=\"quform-option-label quform-option-label-4_113_3\"><span class=\"quform-option-text\">By phone<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-4_98 quform-cf\"><div class=\"quform-spacer\">We will not share your data and you can unsubscribe at any time. If you would like to update or change the way you hear from us, please contact Newlife on 01543 462777 or via email at <a href=\"mailto:info@newlifecharity.co.uk\">info@newlifecharity.co.uk<\/a><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-4_114 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-4_114\"><label class=\"quform-label-text\" id=\"quform_4_114_e9596d_label\">By ticking the statements below, you agree to the terms and conditions (as stated above), confirm that the provision of equipment is necessary and essential to support the named child within this application, and also confirm that this child meets the following criteria: <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-4_114\"><div class=\"quform-input quform-input-checkbox quform-input-4_114 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_4_114_e9596d_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_114[]\" id=\"quform_4_114_e9596d_1\" class=\"quform-field quform-field-checkbox quform-field-4_114 quform-field-4_114_1\" value=\"A UK resident\" \/><label for=\"quform_4_114_e9596d_1\" class=\"quform-option-label quform-option-label-4_114_1\"><span class=\"quform-option-text\">A UK resident<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-4_126 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-checkbox quform-inner-4_126\"><div class=\"quform-input quform-input-checkbox quform-input-4_126 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_126[]\" id=\"quform_4_126_e9596d_2\" class=\"quform-field quform-field-checkbox quform-field-4_126 quform-field-4_126_2\" value=\"Has a disability which affects their daily life and means that equipment is needed, a life threatening\/life limiting condition or has been diagnosed as terminally ill. \" \/><label for=\"quform_4_126_e9596d_2\" class=\"quform-option-label quform-option-label-4_126_2\"><span class=\"quform-option-text\">Has a disability which affects their daily life and means that equipment is needed, a life threatening\/life limiting condition or has been diagnosed as terminally ill. <\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-4_128 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-checkbox quform-inner-4_128\"><div class=\"quform-input quform-input-checkbox quform-input-4_128 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_128[]\" id=\"quform_4_128_e9596d_3\" class=\"quform-field quform-field-checkbox quform-field-4_128 quform-field-4_128_3\" value=\"Under 19 years of age\" \/><label for=\"quform_4_128_e9596d_3\" class=\"quform-option-label quform-option-label-4_128_3\"><span class=\"quform-option-text\">Under 19 years of age<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-4_127 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-checkbox quform-inner-4_127\"><div class=\"quform-input quform-input-checkbox quform-input-4_127 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_4_127[]\" id=\"quform_4_127_e9596d_4\" class=\"quform-field quform-field-checkbox quform-field-4_127 quform-field-4_127_4\" value=\"Agree to Terms and Conditions\" \/><label for=\"quform_4_127_e9596d_4\" class=\"quform-option-label quform-option-label-4_127_4\"><span class=\"quform-option-text\">Agree to Terms and Conditions<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-4_87 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-4_87\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Back<\/span><\/button><\/div><div class=\"quform-button-submit quform-button-submit-default quform-button-submit-4_87\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-submit\" value=\"submit\"><span class=\"quform-button-text quform-button-submit-text\">Send<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div 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