/ FRIDAY CLUB
REGISTRATION FORM
Return to: Leeds Mencap, The Vinery Centre, 20 Vinery Terrace, Leeds, LS9 9LU or
Contact: 0113 235 1331 Fax: 0113 240 9562

Personal Details:

Name

D.O.B

Address

Telephone number

Parent / Carer details (this person will be the first emergency contact):

Name

Address

(if different from member)

Email Address:

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:

Medical Information

Do you have a medical condition that requires medication?

YES NO

If yes, please give details of the condition and any medication required 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?

YES NO

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 you 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 will 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.

I have read, understood and accept this behaviour agreement

Signed Date


Consent

Please read the statement below, sign and date.

·  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.

Signed

Print Name

Date

Membership

For every family who uses a Leeds Mencap service, one family member must become an Associate Member or Full Member. You can become an Associate Member at a cost of £1 or a Full Member for £12 per annum.

Is a member of your family already a member of Leeds Mencap?

YES NO

If you are not currently a member we can arrange membership on your first visit.


We gather the following information to ensure we are offering our services fairly.

Equal Opportunities

Please fill out the next section in order to record the ethnic origin of play scheme attendees. Any information you provide will be kept confidential.

Please tick

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

Photography/Filming consent form

Please PRINT

Name of person to be photographed/filmed:

This person is a:

Service user / X / which service? / Friday Club
Parent/guardian/family member of service user / which service?
Leeds Mencap employee
Leeds Mencap volunteer
Other / please specify:

It has been explained to me that Leeds Mencap requires photographs, voice and video recordings 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 and voice recordings of the above named person from the date stated below.

I understand that any images or recordings may be used by Leeds Mencap at any time, both now and in the future, including on promotional materials, website, and social media.

I accept that I will not be paid or be provided with a different service by Leeds Mencap or its partners as a result of being involved in recordings or photography. I will not own the copyright.

By signing this consent form I agree to all of the above.

Name of consent-giver:

Contact phone/email:

Sign: Date:

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