Registration and Risk Assessment Form

Becoming a member

In order for Independence Project LTD & Independence Clubs CIC to accept or confirm a member of their association you must first apply by filling in our registration and risk assessment form below.

Registration Form

Step 1 of 4

25%

Name of person applying(Required)

Gender(Required)

Date of Birth(Required)

DD slash MM slash YYYY

How did you hear about Independence Project and Independence Clubs?(Required)

Mobile Phone No

Email(Required)

Address(Required)

School or college

Doctor’s surgery & name

Parent/Carer Contact Details

Parent/Carer Name(Required)

Relationship to client(Required)

Home phone number(Required)

Mobile phone number

Email(Required)

Are you completing this form for a Looked After young person (Child in Care)?(Required)

Yes

Social Worker's Name

First

Social Worker's Phone No.

First

Social Worker's Email

First

Emergency Contact Name(Required)

Emergency Contact Relationship(Required)

Emergency Contact Mobile No.

Emergency Contact Phone No.(Required)

Emergency Contact Phone No.

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Mobile No.

SUMMARY OF NEEDS

Please give a brief summary of any disability or difficulties(Required)

What support structures and strategies are used? e.g. routines, or any urgent actions we may need to take. (Further details are required in the Individual Risk Assessment)(Required)

Please give details of any moving/handling needs, personal care needs, need for special equipment/adaptations &/or any communication support needs (further details may be requested)

Please give details of any specific health issues such as epilepsy, asthma, diabetes or food allergies/intolerances

If the client has epilepsy, please give date of the last seizure, how often they occur, triggers and what to do if one occurs:

Does the client carry any medication? If yes, please explain what this is, what it is for and how it is managed (e.g. self-administered or any assistance that may be required)?

Personal Goals: (In clients words if at all possible) What would you like to achieve by participating in Independence Projects training programme (e.g. skills, independence)?(Required)

Other comments/information we should know (including particular projects/groups young person would like to join)?

(Please note Parent/Carer is required to complete this section for young people under 18 years old, and for adults lacking Mental Capacity.) I am applying to take part in Independence Project and Independence Clubs training programme and events. Independence Project and Independence Clubs produces a range of resources to demonstrate the difference our work is making. We like to share the experiences of real people who are using our services in our communications as it helps to illustrate what we do. Please let us know whether you give consent to Independence Project and Independence Clubs to use photographs, feedback, case studies etc.

Internal record-keeping & reports(Required)

Yes

Marketing purposes (in newsletters, reports, leaflets, activity programmes etc)(Required)

Yes

You can choose to have your name published or remain anonymous (in which case, we will use an alias)

I am happy for my name to be used(Required)

Yes

Relationship to young person (if appropriate)

Consent(Required)

I agree to the privacy policy.

By ticking this box you are confirming that you have read this Data Privacy Statement and that you are consenting to Independence Project and Independence Clubs holding and processing your data for the purposes detailed above. (Please note Parent/Carer is required to complete this section for young people under 18 years old, and for adults lacking Mental Capacity.)

INDIVIDUAL RISK ASSESSMENT

This should be completed by a Parent, Carer or other responsible adult

Name(Required)

Independence Project and Independence Clubs has a duty of care to ensure that we have full information about the possible risks to the people we support, and/or any risks to others, so that everyone can participate and be supported safely, whatever their age. Someone who knows a person well (e.g. a parent, carer, teacher, tutor or key worker) needs to complete the following information as accurately and honestly as they can

Road safety awareness(Required)

Poor

Low

Good

Ability to travel on public transport(Required)

Poor

Low

Good

Awareness of other safety issues when travelling or in public places(Required)

Poor

Low

Good

Awareness of risks from approaches from other individuals (‘stranger danger’)(Required)

Poor

Low

Good

Awareness of other dangerous situations(Required)

Poor

Low

Good

Ability to take responsibility for cash /valuables/personal items and information(Required)

Poor

Low

Good

Self-harm (Risk to self)(Required)

Yes

Self-harm (Risk to others)(Required)

Yes

Verbal aggression (Risk to self)(Required)

Yes

Verbal aggression (Risk to others)(Required)

Yes

Physical aggression (Risk to self)(Required)

Yes

Physical aggression (Risk to others)(Required)

Yes

Inappropriate social behaviour (sexual) (Risk to self)(Required)

Yes

Inappropriate social behaviour (sexual) (Risk to others)(Required)

Yes

Inappropriate social behaviour (other) (Risk to self)(Required)

Yes

Inappropriate social behaviour (other) (Risk to others)(Required)

Yes

Substance/alcohol/drug abuse (Risk to self)(Required)

Yes

Substance/alcohol/drug abuse (Risk to others)(Required)

Yes

If you have answered YES to any of the above, please give more information e.g. main triggers for this behaviour, and details of any strategies to be used and/or any behaviour management plan, or other support in place:

Please give details of any other potential concern regarding this person which has not been noted above

Name of person completing this risk assessment(Required)

Role/Relationship to person(Required)

Independence Project and Independence Clubs needs to maintain accurate and up-to-date records of those who use our services, in order to provide safe and effective support.

It is your responsibility to inform us in writing of any changes that occur after a Registration Form has been submitted.

We will then update the information we hold.

This will include any changes to:

Your address
Home phone number
Your mobile phone number
email address
Parent/carer contact details
Emergency contact names or phone numbers
Support needs
Health issues – allergies, asthma, epilepsy, medication etc.
Behaviour or other Risk Assessment issues

Responsibility to provide accurate and up-to-date information(Required)

I confirm that I am providing accurate and up-to-date information now, and understand that I am responsible for informing Independence Project and Independence Clubs of any changes which may occur in the information I have provided.

(Please note Parent/Carer is required to complete this section for young people under 18 years old, and for
adults lacking Mental Capacity.)

This field is for validation purposes and should be left unchanged.

Registration Form

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Whether you are interested in working with us as a supporting company or if you think you have something that can help us on our journey. Maybe you are supporting someone as a carer and would like to join our sessions. We are always interested in hearing from you! Contact us today