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Friday Club registration form
Step
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Personal Details:
Name:
Date of birth:
Day
Month
Year
Address:
Street Address
Address Line 2
City
ZIP / Postal Code
Telephone number:
Parent / Carer details:
(this person will be the first emergency contact)
Name:
Address: (If different from member)
Street Address
Address Line 2
City
ZIP / Postal Code
Email:
Please tick if we can use your email address for sending out information about:
Leeds Mencap Groups only
Other groups for people with learning disabilities
Home Tel Number:
Mobile Number:
Second Emergency contact
Name:
Relationship:
Contact Number:
About you
Do you have a medical condition that requires medication?
Yes
No
If yes, please give details of the condition and any medication required during club hours below.
Do you have a diagnosis for your disability?
Yes
No
If yes, please provide details
Do you use a wheelchair?
Yes
No
If yes, please provide details
Do you have any allergies or any restrictions on the food you are able to eat?
Yes
No
e.g halal, gluten free, vegan
If yes, please provide details
Communication
What form of communication do you use?
E.G. speech, gestures, makaton, pecs, etc.
Language spoken at home:
Support requirements
Please tell us about the things you like doing and the things that you don’t enjoy.
What help do you need to join in the activities and trips out?
Is there anything that might make you feel upset or angry? What can we do to help?
Occasionally there may be fire drills. Do you foresee any problem with participating in the drills? Yes/No If yes, please provide details:
Behaviour Agreement
• All members and their families will be treated equally, fairly, kindly and consistently. • Every child placed in our care will be respected as a person in their own right. • Good behaviour will always be rewarded and praised. • It is acknowledged that members are learning new things and will often make mistakes in their actions and social behaviour. It is our aim to help them progress in their behaviour, to their own pace and abilities. • Parents will be informed of any particular achievements made by their child. • Members will not be labelled, shouted at, told they are bad or stupid. • No system of punishment will be used on the play scheme. • Members who are causing problems by difficult or unacceptable behaviour* will be removed from the initial situation and a member of staff will talk quietly to them about their behaviour and provide alternative activities. • No member will be restrained in any way by a volunteer and will only be gently restrained by a member of staff, should an exceptional and dangerous situation occur. • Staff have the right to ask parents/carers to collect/remove any child who exhibits behaviour that is likely to cause harm or distress to other children, staff or themselves. • Parents/carers will be fully consulted should a problem occur. *Definition of unacceptable behaviour for staff and members- - Swearing - Hitting - Rowdiness - Any behaviour which could bring their or other members, or staff/volunteers safety into jeopardy. - Any behaviour which discriminates against others abilities, race or sex; which includes disregarding the basic needs or respect for members/staff/volunteers and the building. - Inappropriate touching.
Consent
I have read, understood and accept this behaviour agreement
Date
Day
Month
Year
Consent
Please read the statement below: • I certify that the information given on this form is correct. • I give permission to any emergency treatment deemed necessary by a medical professional. I therefore authorise the Leader or Assistant Leader to sign on my behalf any written forms of consent required by hospital authorities should a delay to obtain my signature be considered, in the opinion of the doctor or surgeon concerned, likely to endanger my health or safety. • I understand that whilst every care will be taken by the organisers, they cannot be held responsible for incidents arising out of the unreasonable behaviour of my child or others, nor for the loss or damage to personal property. • I also agree that the Club can share the information, on a need to know basis, to ensure that my child is adequately supported as possible, during Club hours.
Print Name
Date
Day
Month
Year
Images and stories consent form
Name of person(s) to be photographed/filmed/story shared:
This person is a:
Service user
Parent/guardian/family member of service user
Leeds Mencap employee
Leeds Mencap volunteer
Other
If other, please specify
What groups or services does this person attend? (if applicable)
It has been explained to me that Leeds Mencap requires photographs, voice, video recordings and stories/case studies/quotes, in order to show a positive view of the organisation, its employees, volunteers and people that use its services. I consent to all future collection, storage and use of photography, video, voice recordings and stories/case studies/quotes for myself/the above named person(s) (delete as appropriate) from the date stated below.
Yes
No
Please add how you agree these can be used
Service user records such as a child’s development record, a one page profile or a care/support plan
In another service users record (as a group) such as a child’s development record, a one page profile or a care/support plan
In displays within Leeds Mencap premises inc Jimbo’s Community Nursery
On the Leeds Mencap’s and Jimbo’s Community Nursery website and social media (i.e. Facebook/Twitter/YouTube/LinkedIn)
In Leeds Mencap’s, Jimbo’s Community Nursery newsletters, leaflets and other publications
In publicity and fundraising features in the press (e.g. newspapers/radio/TV)
In fundraising literature (e.g. Thank you cards for donors, collection boxes, posters for events)
Funding applications and reports to funders (these are generally not in the public domain)
To use your first name alongside images and stories
I understand that any images, recordings and/or stories/case studies/quotes may be used by Leeds Mencap at any time, both now and in the future. I/the named person(s) above will not benefit in any way as a result of being involved and I will not own the copyright. Consent continues with no time limit, however, it is important that images and stories are up to date, therefore, we will not normally use images or stories for more than three years after the date that they were collected, unless there is a legitimate reason to use them beyond this date. You can change or withdraw your consent at any point, if you would like to do this, please email our Administrator at info@leedsmencap.org.uk or call us on 0113 235 1331. If you withdraw your consent for an image or story to be used, and this has been used for publicity materials, we will stop using these with immediate effect, however, we will not be able to withdraw publicity that has already been circulated. We will remove images from leaflets and publications and reprint following discussion with Fundraising/CEO. We will also be unable to remove historic images from social media
Consent
By signing this consent form I agree to all of the above.
Name of consent-giver:
Contact phone/email:
Date
Day
Month
Year
Equal Opportunities and Monitoring
Please state the type of disability you/your child has:
Specific learning difficulty
Moderate learning difficulty
Severe learning difficulty
Profound & multiple learning difficulty
Social, emotional and mental health
Speech, language and communication needs
Hearing impairment
Visual impairment
Multi-sensory impairment
Physical disability
Autistic spectrum disorder
Other difficulty / disability
SEN support but no specialist assessment of type of need
Please state your child’s ethnicity:
White British
White Irish
Traveller of Irish Heritage
Any other White background
Gypsy/Roma
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed background
Indian
Pakistani
Bangladeshi
Any other Asian background
Caribbean
African
Any other Black background
Chinese
Any other ethnic group
If other ethnic group please state which:
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About us
▼
Our impact
Join our team
Meet the team
Our trustees
Annual accounts
What we offer
▼
Groups and activities
▼
Playschemes for 4 to 18 year olds
Chats & Tots (0-5’s group)
9 to 13 youth group
14 to 18 youth group
Friday club (18-30)
Our Sibling’s Group & Activities
Family support
Information, advice and resources
▼
Info and advice
Resources and activities
Navigating support in Leeds
SEND Toy and Resource Library
Changing Places toilet
Jimbo’s Community Nursery
▼
Playrooms
Room hire
▼
Activity rooms
Meeting rooms
Soft play and sensory rooms
Support us
▼
Fundraise for us
Corporate support
Events
Volunteer
News and stories
▼
Newsletter
Blog posts
Contact us