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Siblings registration form
Step
1
of
7
14%
Childs Details:
(child who will be attending the siblings group)
Name:
Date of birth:
Day
Month
Year
Gender:
Address:
Street Address
Address Line 2
City
ZIP / Postal Code
Ethnicity:
Religion:
School:
Parent / Carer Details:
Name:
Address:
Street Address
Address Line 2
City
ZIP / Postal Code
Email:
Home Telephone:
Mobile Number:
Emergency Contact Numbers
In the case of emergency we will look to contact the following people in order. Please make sure that mobiles are switched on and contacts available during the session.
1:
Name:
Relationship:
Contact Number:
2:
Name:
Relationship:
Contact Number:
Support Information
Does your child have any medical needs such as epilepsy, asthma or other health related conditions?
Does your child have any allergies or dietary requirements?
Does your child have any mental health, behavioural or other support needs?
Information about the family:
Information about sibling with a disability:
Name of sibling:
Date of birth:
Day
Month
Year
Sibling’s disability:
Additional information:
Include information about parents/carers and siblings and the impact of having a disabled sibling on the child/young person who is applying to join the Siblings Group.
What support do you think your child would benefit from?
Tick all the apply
A chance to meet other siblings
To learn more about their siblings disability
Opportunity to speak 1:1 with a member of staff
Chance to share and hear other children’s experiences of having a sibling with a disability
Opportunity to have a break and have fun
Support with any caring role that they might have
Opportunity for trips out – bowling, cinema, meals out
Support them to have a positive view/ relationship with their sibling
Support with their own mental wellbeing
Consent Form
I hereby certify that the information given on this form is correct, and I have parental responsibility/delegated authority for this child.
Yes
No
I give my permission for Leeds Mencap staff to:
Administer first aid if needed?
To seek medical advice or treatment?
To take trips outside of the Vinery Centre e.g. bowling, park trip?
Print Name:
Date
Day
Month
Year
Your details and contact from us
We will store your contact details on our database. Your child’s details will be stored confidentially. Please let us know how you would like to receive information from us. Please tick all your preferences.
General information – Including our newsletter, this may be information about our services and ways you can help, such as volunteering, how to donate to us or how you can get involved in activities like fundraising.
Post
Telephone
Email
SMS Text
Service User information – Please also tell us how would you like to continue to receive information from us about accessing Leeds Mencap services and other services in Leeds.
Post
Telephone
Email
SMS Text
How did you hear about Leeds Mencap Siblings Group?
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:
Which service/s do they use?
For example: Siblings group, Activity groups
Consent
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.
I agree
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
By signing this consent form I agree to all of the below:
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
I agree
Name of consent-giver:
Contact phone/email:
Date
Day
Month
Year
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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
