Information for the Sensory Team Please tick and complete the information that you are happy to share: Please tick whether your child has a hearing impairment and/ or vision impairment: Required Hearing Impairment Vision Impairment Child’s first name: Required Child’s last name: Required Date of Birth: Required Address: Required Postcode Lookup Parent/carer name 1: Required Parent/carer name 2: Telephone numbers: Landline: Mobile 1: Mobile 2: Email 1: Email 2: Do you receive the Sensory Team Newsletter: Required Please select.. Yes No Please consider following this link www.stoke.gov.uk/sensorynews to sign up to receive these automatically by email. As part of our ongoing monitoring and assessment, we may complete assessments with your child e.g. language assessments. We may use video recording as part of this process. Please contact us if you wish to discuss this further. Phone Number: 01782 232538 Email: SEND@stoke.gov.uk