serk specialised equipment request form · serk specialised equipment request form . ... the...
TRANSCRIPT
SERK Specialised Equipment Request Form
The SERK Program is funded by the Queensland V.1 Released January 2019 – Page 1 of 5 Government Department of Education © KU Children’s Services 2019
The Specialised Equipment and Resources for Kindergarten (SERK) program is funded by the Queensland Government, Department of Education, to provide assistance to Kindergartens working under Central Governing Bodies to address barriers to inclusion. This assistance may include access to the Specialised Equipment Library which is managed by KU Children’s Services.
Equipment and Aids under SERK are available for loan at no cost to approved Kindergarten Services, to support children with disabilities or additional needs.
This form is to be completed and returned to the SERK team:
Email: [email protected] Phone: 07 3865 4780 Post: 3/151 Granite Street, Geebung QLD 4034 KINDERGARTEN DETAILS
Kindergarten name: ____________________________________________________________________
Address: _____________________________________________________________________________
Suburb: _____________________________________________ Postcode: ________________________
Contact person: ______________________________________ Position: _________________________
Phone: ____________________________ Email: ____________________________________________
SERVICE TYPE
Kindergarten Program Provider or a Legacy funded Kindergarten Service holding membership with a Central Governing Body (CGB):
Yes No
C & K Catholic Independent Lutheran Gowrie
CHILD’S DETAILS/CONSENT/EQUIPMENT REQUESTED
Name of child: ________________________________________________________________________
Date of birth: _________________________________________ Male Female
Medical diagnosis: _____________________________________________________________________
Please attach confirmation of disability (e.g. Specialist’s diagnosis or letter stating undergoing assessment)
Number of days attending Kindergarten: ___________________________________________________
Parent/guardian consent to request equipment/aids
Parent/Guardian Name: _________________________________________________________________
Signature: ______________________________________________ Date: _________________________
SERK Specialised Equipment Request Form Continued...
The SERK Program is funded by the Queensland V.1 Released January 2019 – Page 2 of 5 Government Department of Education © KU Children’s Services 2019
ITEM Piece/s of equipment required i.e. posture chair, cut out table
SPECIFICATIONS OF EQUIPMENT Model, size, specification, accessories required
Continue on separate page if required
THERAPIST TO COMPLETE THIS SECTION (MANDATORY)
Name of Therapist: ____________________________________________ PT OT SLP
Organisation: _________________________________________________________________________
Phone: ____________________________ Email: ____________________________________________
Signature: ______________________________________________ Date: ________________________
Background information
Describe the child’s functional status and abilities in the following areas:
Physical function:
SERK Specialised Equipment Request Form Continued...
The SERK Program is funded by the Queensland V.1 Released January 2019 – Page 3 of 5 Government Department of Education © KU Children’s Services 2019
Sensory: Cognitive/perceptual skills:
SERK Specialised Equipment Request Form Continued...
The SERK Program is funded by the Queensland V.1 Released January 2019 – Page 4 of 5 Government Department of Education © KU Children’s Services 2019
KINDERGARTEN SUPPORT PLAN
The aim of a Kindergarten Support Plan (KSP) is to support the request for equipment/aids. How does the equipment/aids applied for assist in supporting the participation of the child with a disability into the Kindergarten Service? How does the equipment practically fit into the Kindergarten environment, and what strategies has your Kindergarten developed to store and maintain them whilst at your service?
KINDERGARTEN SERVICE AUTHORISATION
Name of Service representative: __________________________________________________________
Signature: ______________________________________________ Date: _________________________
SERK Specialised Equipment Request Form Continued...
The SERK Program is funded by the Queensland V.1 Released January 2019 – Page 5 of 5 Government Department of Education © KU Children’s Services 2019
APPENDIX (COMPLETE WHERE REQUIRED)
ITEM Piece/s of equipment required i.e. posture chair, cut out table
SPECIFICATIONS OF EQUIPMENT Model, size, specification, accessories required