White A1 British A2 Irish A3 Any other white background □ □ □ Mixed B1 White & Black Caribbean B2 White & Black African B3 White & Asian □ □ □ B4 Any other mixed background □ Asian C1 Indian C2 Pakistani C3 Bangladeshi C4 Any other Asian background □ □ □ □ Black or Black British D1 Caribbean D2 African D3 Any other Black background □ □ □ Chinese or Other Ethnic Background E1 Chinese E2 Any other (please write in): □ Disability The Disability Discrimination Act 1995 defines a disabled person as anyone with a or mental impairment that has a substantial and long term adverse effect upon “physical his/her ability to carry out normal day-to-day activities.” Please choose the description that best describes the nature of the child’s disability and tick the appropriate box. A Visually impaired D Learning disability □ □ B Hearing impaired E Multiple disability □ □ C Physical disability F Other (please write below) □ You may wish to discuss your concerns with someone outside of the organisation to gain reassurance. The NSPCC Helpline can help with this, and is confidential. NSPCC Helpline: 0808 800 5000
White A1 British □ A2 Irish □ A3 Any other white background □ Mixed B1 White & Black Caribbean □ B2 White & Black African □ B3 White & Asian □ B4 Any other mixed background □ Asian C1 Indian □ C2 Pakistani □ C3 Bangladeshi □ C4 Any other Asian background □ Black or Black British D1 Caribbean □ D2 African □ D3 Any other Black background □ Chinese or Other Ethnic Background E1 Chinese □ E2 Any other (please write in): Disability The Disability Discrimination Act 1995 defines a disabled person as anyone with a “physical or mental impairment that has a substantial and long term adverse effect upon his/her ability to carry out normal day-to-day activities.” Please choose the description that best describes the nature of the child’s disability and tick the appropriate box. A Visually impaired □ D Learning disability □ B Hearing impaired □ E Multiple disability □ C Physical disability □ F Other (please write below) You may wish to discuss your concerns with someone outside of the organisation to gain reassurance. The NSPCC Helpline can help with this, and is confidential. NSPCC Helpline: 0808 800 5000
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