Join the Children with Disabilities Network and apply for a Max Card Details of child Name Child's first name* Child's last (family) name* Child's date of birth (DD/MM/YYYY)* Child's address If you are applying for a Max Card, it will be sent to this address. Postcode* Select your address * Address You have selected: Address Change address Child's school Gender Male Female Prefer not to say Ethnicity Please select British Irish Other White and Black Caribbean White and Black African White and Asian White and Arabic / Middle Eastern Other Indian Pakinstani Bangladeshi Sri Lankan Other Caribbean African Other Chinese Arab Iranian Other Any other ethnic group Prefer not to say Child's condition or disability Has your child been diagnosed with any conditions or disabilities * Yes No Please list all conditions or disabilities your child has been diagnosed with Is your child being assessed for any conditions or disabilities? * Yes No Please list all conditions or disabilities your child is being assessed for Support services What support services does your child use, and how frequently? For example, services may include: Occupational Therapy, Speech Therapy, Physiotherapy, Child Care, Voluntary / Charity Organisations, Mental Health Service, Children with Disabilities Social Work Team, Children and Young People's Service (health) etc. Frequency may be: daily, weekly, monthly. What other services do you feel would be useful to you? This includes activities you would like your child to take part in. Child's main carer Your name Title * Please select Mr Mrs Miss Ms Dr Cllr First name* Last (family) name* Your email Email address* Confirm email address* We will send a confirmation of your application to this email address. I am happy to get emails about local events and things to do for children with disabilities (please note, most information from the Network is provided via email) Phone number We will only call you if we need more information to process your application form. Does this carer live at the same address as the child? * Yes No Carer's address Postcode Select your address Address You have selected: Address Change address Second carer Would you like to add details of another carer? * Yes No Second carer details Your name Title Please select Mr Mrs Miss Ms Dr Cllr First name Last (family) name Your email Email address Confirm email address Phone number Does this carer live at the same address as the child? Yes No Second carer's address Postcode Select your address Address You have selected: Address Change address Max Card What is a Max Card? Max Cards give you free and discounted to entry to over 1,500 cultural and leisure attractions, many of which are in South Tyneside and the North East. To be eligible for a Max Card, your child needs to either: have a diagnosed condition / disability currently being assessed for conditions / disabilities Find out more about Max Cards. Would you like to apply for a Max Card? Yes No Have you had a Max Card before? Yes No Max Card survey Please let us know how you have used your Max Card in the past. Select the places that you have used your Max Card and let us know how many times. Swimming and gym Hebburn Central swimming pool Haven Point swimming pool Jarrow Pool Tyne and Wear Arbeia Roman Fort The Ark at Crawcrook (Ryton) BALTIC Centre Bedlam Lasertag (Newcastle) Bedlam Paintball (Newcastle) Bedlam Lasertag (Tyneside) Bedlam Paintball (Sunderland) Blue Reef Aquarium Centre for Life Dance City Discovery Museum Eldon Leisure Centre Escape Key (Newcastle) Gibside Go Ape (Maften Hall) Gosforth Pool Great North Museum Hatton Gallery Jarrow Hall Laing Art Gallery Live Theatre Mister Twisters National Glass Centre Nationwide Paintball (Newcastle) NE Land, Sea, Air Museum Never Give Up (Newcastle) Newcastle Castle Newcastle Climbing Centre Northern Stage River Escapes Segedunum Roman Fort Seven Stories South Shields Museum Splatmaster (Newcastle) Splatmaster (Sunderland) Squiggles N Giggles Stephenson's Railway Museum Sunderland Bowl Sunderland Museum and Winter Gardens Team Sport (Newcastle) The Customs House The Globe Gallery Shipley Art Gallery Tyneside Cinema Washington F Pit Washington Old Hall Washington Wetlands West Denton Pool The Word, The National Centre for the Written Word Virgin Experience Days (Newcastle) Virgin Experience Days (North East) Northumberland Alnwick Castle Alnwick Gardens Bailiffgate Museum Bamburgh Castle Bedlam Paintball (Hexham) George Stephenson's Birthplace Heatherslaw Corn Mill Hexham Old Gaol Lady Waterford Hall Morpeth Chantry Bagpipe Museum Northumberland Zoo Seaton Delaval Hall SplatMaster Hexham Woodhorn Museum Tees Valley Bedlam Paintball (Middlesborough) Bedlam Lasertag (Scotch Corner) Bedlam Paintball (Scotch Corner) Captain Cook Museum Cleveland Ironstone Mining Museum Dorman Museum Guisborough Museum Hartlepool Art Gallery Hartlepotz Hollywood Bowl (Stockton) Juvenate Health and Leisure Club (Middlesborough) Kirkleatham Museum Nationwide Paintball (Middlesborough) The Pottery Loft (Stockton) RSPB (Saltholme) Splatmaster (Scotch Corner) Tweddle Farm Two Hoots Zetland Lifeboat Museum County Durham Adventure Point (Darlington) Adventure Valley Bedlam Paintball (Darlington) Bedlam Paintball (Durham) Binchester Roman Fort The Bowes Museum Botanic Gardens Beamish Museum Beamish Wild Bishop Auckland Table Tennis Centre Cherryburn (Stocksfield) Crook Hall and Gardens Durham Cathedral Darlington Railway Museum Darlo Play Plaza Holmside Park Killhope Lead Mining Museum Krazy Kingdom (County Durham) Nationwide Paintball (Darlington) Shildon Railway Museum Oriental Museum ROF59 (Newton Aycliffe) Splatmaster (Durham) Weatherriggs Animal Rescue Please list any attractions outside of the North East which you have visited with your Max Card. 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