- Course places are limited, so we do give priority to people who haven’t been on a course before, or who have the most potential to benefit. If you are applying for another course with us, please give us a call to discuss what you are hoping to achieve.
- Please state on the form if you have a strong preference for a particular course. You can apply for more than one course but will usually only be offered a place on one.
- Please answer all questions as fully as possible. The information given will be treated in confidence and shared on a necessary basis, and will enable us to support you as much as possible to meet your personal care needs if applicable.
- There are some FAQs available on our website. You may find these useful when making an application.
1 / PERSONAL DETAILS
Title / First name / Last name / DOB
Address 1 / Address 2
Town / Postcode
Telephone / Mobile
Height (cm) / Weight in (kg)
2 / COURSE CHOICE
Please tick your preferred course. We hope to offer a place on your first choice, but your flexibility helps!
COURSE / LOCATION / DONATION / DATE / TICK
Skills for Independence / Coventry / £220 / Monday 9 – Friday 13 April 2018
Over 50s Multi Activity 5 day / Exmoor / £330 / Monday 16 – Friday 20 April 2018
Next Steps / Newcastle / £220 / Monday 23 – Friday 27 2018
Multi Activity 7 day / Lake District / £440 / Saturday 12 – Saturday 19 May 2018
Multi Activity 5 day / Exmoor / £330 / Monday 4 – Friday 8 June 2018
Back Up to Work / Newcastle / £140 / Tuesday 12 – Thursday 14 June 2018
Moving Forwards 18-25s / Leeds / £220 / Tuesday 21 – Saturday 25 August 2018
City Skills / Edinburgh / £500 / Thursday 30 August – Tuesday 4 Sept 2018
Next Steps / Bath / £220 / Friday 7 – Tuesday 11 September 2018
Over 50s Multi Activity 5 day / Lake District / £330 / Monday 10 – Friday 14 September 2018
Skills for Independence / Coventry / £220 / Friday 5 – Tuesday 9 October 2018
Back Up to Work / TBC / £140 / November 2018
*All dates are subject to confirmation; please check the calendar on our website for updates
3 / YOUR AIMSHow do you feel you would benefit from attending a Back Up course? If you have done a Back Up course before, what will be the new challenge for you by attending another course?
What has prompted you to apply for a course place?
Services Brochure / Back Up Website / Back Up Staff Member
Back Up leaflet / Transform newsletter / Courses Calendar
Event stand / Facebook / Twitter
YouTube video / Hospital/SIC Staff Member / Spinal Centre noticeboard
Recommendation / Other…please state
4 / INJURY DETAILS
Injury level (please state)
Is your injury…. / Complete Incomplete
If your injury is incomplete, please give details of movement/sensation below your injury level:
Date of injury / Cause of injury
Please rate the following:
Balance Good Average Poor None
Strength Good Average Poor None
Grip Good Average Poor None
Do you have any problems with pain? YES NO
If yes, please give details of management:
Do you have any problems with spasm? YES NO
If yes, please give details of management:
5 / WHEELCHAIR INFORMATION
What type of wheelchair do you use (if applicable):
Manual (full time) Manual (part time) Manual with power assisted wheels
Hand control power chair Chin control power chair Head control power chair
I don’t use a wheelchair I walk with aids Other: please state
If applying for skiing, please state the following necessary chair dimensions:
weight (kgs) / height (cm) / width (cm) / length (cm)
6 / ASSISTANCE WITH PERSONAL CARE
Back Up has a team of experienced voluntary spinal cord injured trained nurses and PAs (Personal Assistants)
I do not need assistance with my personal care
I need assistance with my personal care – we will contact you to discuss arrangements
7 / TRANSFERS
Can you independently transfer from bed to another surface if they are on an equal level? YES NO
If not, which method of transfer do you use? Lifted Standing Transfer Hoisted Other
Do you use equipment to enable you to independently transfer? YES NO
If yes, please give details:*
8 / WASHING
Do you use a shower chair? YES NO
If yes, please specify: Pull down shower seat Self-propelled shower chair Other
Can you transfer from chair to shower chair independently? YES NO
Do you require assistance with washing? YES NO
9 / DRESSING
Do you require assistance with dressing? YES NO
If yes, please indicate which items of clothing you require assistance with:
Tops Trousers Socks Shoes Gloves All items
10 / EATING AND DRINKING
Can you eat and drink independently? YES NO
If no, please give details of any assistance required:
Do you use any equipment to assist with eating and drinking? YES NO
If yes, please give details:
11 / BOWEL MANAGEMENT
Do you require assistance with your bowel management? YES NO
Please give information on your bowel management routine including frequency, time of day & procedures used:
12 / BLADDER MANAGEMENT
What sort of bladder management do you use?
Indwelling Catheter Intermittent Catheter Suprapubic Catheter Sheath Drainage
Other Please specify:
Do you have a history of UTIs? YES NO If yes, please give details of your last episode:
13 / SKIN CARE MANAGEMENT
Do you currently have any pressure sores/problems with your skin? YES NO
If yes, please give details including site of sore, any medication, medical advice sought:
14 / NIGHT CARE
Do you require assistance turning during the night? YES NO
If yes, please give details of assistance required:
Are you able to sit up independently in bed? YES NO
15 / COURSE DONATION
Back Up receives no government funding and relies on the generosity of individuals and companies to fund our programme of courses. Each year we ask all course participants to make a suggested donation towards their place. This is around a third of what it actually costs Back Up.
But we understand that this isn’t possible for everyone and don’t ever let money concerns stop you from applying for one of our courses: we never allocate or refuse a course space based on your ability to make a donation. Please tick one of the following options:
I would like to donate the full cost of my course space if I go on the course (please contact us for details)
I would like to donate the full suggested donation if I go on the course
I would like to donate another amount of £ towards the charity's costs
I would like to do some fundraising or try to get sponsorship for Back Up
I would like someone to contact me personally to discuss funding
I am unable to make a donation
16 / OTHER COMMENTS
Is there any reason you may need to withdraw from a course? Yes No
If yes, please specify:
Please use this space or an additional sheet for any other comments, concerns or questions you may have:
Please ensure that you take any required equipment and medical supplies/medication with you on a course. If you would like to discuss any other aspects of your personal care, please contact the office.
I verify that the information given is accurate and true to the best of my knowledge at the time of application. If there are any significant changes in my circumstances, particularly health, (e.g.: sustain an injury, pressure sore, pregnancy) I will let Back Up know immediately.
Signed / DateWe would like to contact you with information about our services and how you can support us, including ways to volunteer, take part in research, how you can donate to us and get involved in our fundraising activities and events.
We promise to always keep your details safe and we will never share your details with any third party. (unless we feel you are at risk - as outlined in our safeguarding policy)
Yes, please contact me by (please tick)
Email Phone Text Post
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Please return your completed form via email
or post to Back Up, 4 Knightley Walk, London, SW18 1GZ
Reg Charity Number 1072216 and SC040577 Charitable Company No 3596996 Registered in England & Wales