The Weekender Membership Form

YourPersonal Details
Full Name / Date Of Birth
Address / Gender
Your Contact Number:
Ethnicity
(e.g White/British)
Religion
Postcode / What other sessions do you attend? / Young Women’s Project
The Jam
What school or college do you attend / Please list any siblings who attend the centre
Emergency Contact Information
(appropriate adult aged over 18)
Parent/GuardianName
Address (if different above) / Emergency Contact Number:
Relation to you? / 2nd Emergency Number:
Which activities would you be most interested in: (Please Tick)
Football / Multi Sports / Arts & Craft
Pool/Table Tennis / Discussions/Workshops / DJ Skills/Music
Computers / Cooking / Education/Careers Advice
Disabilities & Medical Conditions

Do you have a Learning Disability: Yes No (e.g. Dyslexia, ADHD, Autism)
If yes, please give details:

Do you have a Physical Disability: Yes No (e.g. Speech & hearing impairment)
If yes, please give details:

Do you have any Medical Conditions: Yes No (e.g. Asthma, health condition)
If yes, please give details:

Do you suffer fromany allergies: Yes No (e.g. hay fever, peanut allergy, bee stings)
If yes, please give details:
Statement
I am happy for Hounslow Action for Youth (HAY) to keep my personal information on record. I will inform HAY if there are any changes to the details I have provided.
Sign / Date

Please turn over

Important Information

Information Sharing
Hounslow Action for Youth (HAY) keeps information about you to make sureyou get the best help possible. Information is stored securely on a database system called Lamplight.
We often use information from this database to gather statistics to apply for funding. The information we use is anonymous and will not share personal details about you.
Sometimes information may be shared with other services if they are involved with you or your family so we can work together to support you but we need your permission before we do this.
Are you or your family involved with Social Service, CAMHS, Early Help Hounslow or another agency:
Yes No If Yes, please give details:
Please tick whom (if any) you would be happy for us to share your information with.
Who we can share information with: (Please Tick)
School / Social Care
CAMHS / Other:
Confidentiality
Personal information you discuss with staff will be kept confidential but if you disclose information to us that suggests you or someone else is likely to suffer harm or a crime is being committed, we have a duty of care to report this to the relevant agency. In this situation, we do not need your permission but will inform you of our concerns and let you know who we will be passing the information on to.
Statement
I have read and understood the information above and am happy for staff at HAY to record information about me and share information with the agencies I have ticked from the list above. I understand that the staff have a duty of care and can pass information without my permission if there is a legal requirement to do so.
Sign / Date
Code of Conduct
I have read and understood the Code of Conduct and am aware that breach of the code can result in mymembership being suspended or withdrawn.
Sign / Date
Office Use Only
Membership form checked by member of staff / Date completed: / Staff signature:
Parent Consent for photos Yes /No / Form dated: / Staff signature:
Membership form on Lamplight / Date completed: / Staff signature: