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 NoEmail(Required)Address(Required)School or collegeDoctor’s surgery & name Parent/Carer Contact DetailsParent/Carer Name(Required)Relationship to client(Required)Home phone number(Required)Mobile phone numberEmail(Required) Are you completing this form for a Looked After young person (Child in Care)?(Required) Yes No 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 NameEmergency Contact RelationshipEmergency Contact Mobile No. SUMMARY OF NEEDSPlease 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/intolerancesIf 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 No Marketing purposes (in newsletters, reports, leaflets, activity programmes etc)(Required) Yes No 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 No 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 ASSESSMENTThis should be completed by a Parent, Carer or other responsible adultName(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 canRoad safety awareness(Required) Poor Low OK Good Ability to travel on public transport(Required) Poor Low OK Good Awareness of other safety issues when travelling or in public places(Required) Poor Low OK Good Awareness of risks from approaches from other individuals (‘stranger danger’)(Required) Poor Low OK Good Awareness of other dangerous situations(Required) Poor Low OK Good Ability to take responsibility for cash /valuables/personal items and information(Required) Poor Low OK Good Self-harm (Risk to self)(Required) Yes No Self-harm (Risk to others)(Required) Yes No Verbal aggression (Risk to self)(Required) Yes No Verbal aggression (Risk to others)(Required) Yes No Physical aggression (Risk to self)(Required) Yes No Physical aggression (Risk to others)(Required) Yes No Inappropriate social behaviour (sexual) (Risk to self)(Required) Yes No Inappropriate social behaviour (sexual) (Risk to others)(Required) Yes No Inappropriate social behaviour (other) (Risk to self)(Required) Yes No Inappropriate social behaviour (other) (Risk to others)(Required) Yes No Substance/alcohol/drug abuse (Risk to self)(Required) Yes No Substance/alcohol/drug abuse (Risk to others)(Required) Yes No 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 aboveName 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.)EmailThis field is for validation purposes and should be left unchanged.
