Friends for Life Application form received ____/____/____
Service Users Name:
DOB:
Address (include post code):
Home Tel No:
Name of School/ College/Work:
Ethnicity
Mother/Guardian (please delete, as appropriate)
Name:
Home Address:
Work Address:
E-Mail Address:
Mobile Tel No:
Home Tel No:
Father/Guardian (please delete, as appropriate)
Name:
Home Address:
Work Address:
E-Mail Address:
Home Tel No:
Mobile Tel No:
Other Family Members
Name and Age
Relationship
Do any of the other family members have additional support needs? :
Emergency Contact (Not parent or guardian)
Name:
Doctor
Name:
Address:
Practice Address:
Practice Tel No:
Tel No:
Relationship to Child:
Social Worker
Name:
Office Address:
Team:
Tel No:
Mobile Tel No:
Have you (the service user) been diagnosed with any additional support needs?,
Autism
A.D.H.D.
Other please state:
Cerebral Paulsey
Downs Syndrome
Learning Delay
Do you (the service user) have any known medical problems, ie asthma, allergies, epilepsy?
Yes
No
Yes
No
Yes
No
If so, please detail causes and symptoms, etc:
Do you (the service user) have any special dietary requirements?
If so, please detail:
Are you (the service user) on any regular medication?
If 'yes', please give details and include name and dosage taken:
Please detail what your (service user's) special needs are, eg behaviours, mannerisms:
Any other information about you (the service user) or your care, eg routine, feeding, toileting that we
could use to improve your care whilst at the club:
How do you (the service user) manage with the following and what level of assistance do you require?
Walking:
Understanding:
Speech:
Hearing:
Co-ordination:
Eating:
Toileting:
Do you (the service user) utilise any special terms, gestures, words?
Do you (the service user) prefer any particular types of games or equipment?
How would you describe your character, e.g. sociable or likes own company?
What level of supervision do you (the service user) require to enable participation in daily activities?
Indoors:
Outdoors:
Are there any situations that may give rise to behaviour problems?
If you (the service user) get upset for any reason, what is the best way of calming you down?
Any other relevant information or family circumstances that will help us care for you (the service user)?
Do you (the service user) ever use respite?
If 'yes', please give details, as follows:
Yes
Address:
Tel No:
No
Do you (the service user) go to any other clubs/activities? If so, where and what days?
Can we use cosmetics?
Yes
No
Do you (the service user) require help with administering medicine?
Yes
No
I give permission for sun protection to be applied, if I have not brought my own:
I will supply the club with sun protection:
Yes
No
Yes
No
CONSENTS: Please read the consents below and mark them as appropriate.
Some of the routine activities of the club may involve visits or other short trips off the
premises. For you (the service user) to take part in these activities we must have your
written consent. (For major trips and outings, a consent form requesting your permission will
be sent home with you or through the post).
I do/do not*
agree to taking part in the excursions described above.
I consent/do not consent*
I consent/do not consent*
to allowing my photograph to be taken whilst at the club.
to photographs being used for publicity as seen fit by the club.
I consent/do not consent*
to undergoing any emergency medical treatment necessary
during the running of the club.
I authorise/do not authorise* staff to sign any written form of consent required by the
hospital authorities if the delay in getting my signature is
considered by the doctor to endanger my health and safety.
Should I need to take medication which has been prescribed by my GP –
I authorise/do not authorise* staff to administer this medication as prescribed and on my
instruction only.
* Delete as appropriate
I have read the information leaflet and agree to the following:
(a)
Pay fees in advance.
(b)
Phone as early as possible if I will be absent from the club.
(c)
Give one week's notice in writing to terminate the place at the club.
(d)
Collected by the official closing time for that day.
(e)
Should somebody different be collecting me, I shall notify a member of staff in
advance.
(f)
I understand that I will be expected to abide by the club's rules and failure to do so
could result in possible expulsion.
(g)
I accept that I am responsible for my own property whilst attending the club.
Please note that if your application for membership is accepted, this registration form will be
the basis of your contract with the club.
I have read the above consents requests and have marked them as appropriate.
I agree to the terms and conditions as detailed in our Information Booklet.
Signed
Date
OFFICE USE
Service User's birthday noted in diary
Staff trained in administration of medicine, if required
Information Book Sent
Induction done by:
Visit
ADMINISTRATION OF MEDICATION
PARENT/GUARDIAN CONSENT FORM
CHILD’S DETAILS
Name:
Date of Birth:
Reason for Medication:
MEDICATION DETAILS
Name of Medicine:
Date of Expiry
and Dispensed Date:
Type of Medication (Oral, Injection,
Inhaler):
PARENT/GUARDIAN CONSENT
I agree for my child to be administered the medication as detailed above.
I……………………..…..give consent for ………………………... to be given………x……..mls of…………………………….
Additional comments
Parent/Guardian’s Name:
Relationship to Child:
Signature:
Date:
Date
received
last
dosage
given at
home
28 day review of
medication
Staff
Initials
Medication
Quantity
&
Dosage
Time
Administered
by;
Witnessed
by;
Returned &
signed by
Parent/carer
Parent/ carer comments
Time and course
expired
Should there be no response after giving a child life saving medication e.g. asthma inhaler, epi
pen, etc you must seek medical help immediately by phoning 999.
Revised 21.03.14
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Primary School