Disclaimer for clients attending Brent Mencap sports sessions with support staff
Purpose of disclaimer- as some clients may attend with support staff they may not want to give us all information required to provide safe, accessible activities. We are still happy for these clients to take part and will only collect monitoring information such as name, date of birth, address, support agency details, photograph consent, diversity information as well as a signed data consent form.
We expect staff who are supporting clients to attend to have all relevant information regarding communication, support needs, behaviour management, medical conditions, medication, next of kin, dietary and potential risks and to ensure any relevant information to ensure the safety of clients is passed to Brent Mencap worker and the coach at each session.
Brent Mencap assumes that each person participating in the activities is healthy and has no medical condition that would preclude him or her from participating in the activities, unless we have been given specific medical details.
Support staff should not allow their clients to participate in an activity if any medical, physical or other factor indicates that he or she is not suited to that activity. Where there are any queries or concerns about such matters, the consent of the participant, GP and/or parent/carer should be obtained by the service before allowing participation.
Adult supervision must be provided at all times for all activities where participants require additional support.
If there is an emergency, the clients support staff will need to deal with this accordingly for example contacting next of kin, giving information to emergency services.
Name of service:______
Signature of support service representative: ______
Date:______
Brent Mencap – Referral Form (for clients attending with support)
/ Full Name / ……………………………………………….Date of Birth
/ Address
Email / ......
………………………………………………..
……………………………………………….
……………………………………………….
/ Home telephone number / ………………………………………………..
/ Mobile / ……………………………………………….
/ Gender / Female Male
/ Are you currently a member of Brent Mencap? / Yes No
/ Agencies involved
Name & contact details of person/organisation supporting them on activities. / ………………………………………………..
………………………………………………..
………………………………………………..
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/ Are you registered with Social Services as a person with a Learning Disability? / Yes No
What type of Learning Disability do you have? / ……………………………………………….
/ Do you have any other disabilities or special needs? (e.g. visual or hearing difficulties, problems with walking, moving or feeding yourself). / Yes No
……………………………………………….
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/ How do you communicate? / Speech Yes No Gestures Yes No
Sign Language Yes No
/ What language do you speak? / ………………………………………………
/ Do you have any behaviour which is difficult to manage?
If yes how do you deal with this? / Yes No
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/ Have you ever run away or hidden? / Yes No
/ Have you ever gone missing from a club or whilst out on a trip?
If yes please give details / Yes No
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/ Are you currently taking any medication from your doctor or hospital? / Yes No
/ Please tell us the name of this medication and what it is for.
Do you take these by yourself or do you need support? / ……………………………………………….
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/ Do you have any medical conditions?
If yes please tell us more about them / Yes No
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/ Are you allergic to anything?
If yes please tell us what you are allergic to / Yes No
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/ Are you continent?
If no please tell us more / Yes No
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/ Would you like to take part in the fitness sessions? / Yes No
/ Have you asked your GP if you fit/healthy enough to take part?
If yes please tell us what they said.
If no please see your GP / Yes No
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/ Are there any risks which may cause harm to you, staff or other people on the football project?
If yes please tell us what they are / Yes No
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/ Please give us details for your next of kin / 1: Name......
Address…………………………………
………………………………………………
Home number:……………………..
Mobile number:……………………..
Worker number:……………………
Email: …………………………………..
______
2: Name…………………………………
Address…………………………………
………………………………………………
Home number:……………………..
Mobile number:…………………….
Worker number…………………….
Email:……………………………………
/ Doctors details / Name……………………………………..
Address………………………………….
………………………………………………..
Telephone number
……………………………………………….
/ Photograph permission
Brent Mencap often takes photographs of people to use in our newsletter, for funding purposes and in the media (e.g. local paper).
Are you happy to be in photographs or videos? / Yes No
Brent Mencap Diversity Monitoring Questionnaire
We need to know this information so we can be sure we offer a fair service or employ a diverse workforce. Our Funders also ask us to give them information about the people we give services to. The form is based on Brent Council’s form.
Please tick the relevant boxes. It is confidential. If you don’t want to give all or some of your details please tick the bottom box “prefer not to say”
I would describe my race or ethnic origin as
Asian BangladeshiAsian Indian
Asian Pakistani
Asian British
Asian Other (Please specify)
Black African
Black Caribbean
Black British
Black Other (Other Please Specify)
Chinese
Chinese British
Chinese other
Mixed - white and Asian
Mixed – white and Black African
Mixed - white and Black Caribbean
Mixed Other (Please Specify)
Other (Please Specify)
White - British
White – Irish
White – Other (Please Specify)
Prefer not to say
Gender
MaleFemale
Belief
ChristianMuslim
Jewish
Buddhist
Sikh
Jain
Hindu
Baha’i
Other (Please specify)
No religion
Prefer not to say
Age Please tick box your age falls into
0-4 / 5-11 / 11-16 / 16-18 / 18-25 / 26-35 / 36-45 / 46-55 / 56-65 / Over 65Do you consider yourself to have a disability / Yes / No
Sexual Orientation (Only answer if you are aged 16 or above)
HeterosexualLesbian
Gay
Bisexual
Prefer not to say
Agreed Feb 2009 Exec
Consent form
According to the 1988 Data Protection Act,Brent MENCAP must tell you why information
about you is collected. We must also tell you
what we will use this information for and how
we will store it
Your information will be used
To pass onto other people or professionals. These could be a social worker, housing officer, health staff, benefits agency or other individuals to help us support you. /To collect information about who uses our services. This will be used in our reports about Brent Mencap. It will also be used to try to improve the service we provide and to keep you informed about what Brent Mencap is doing /
We will store this information
On a computer in our offices andwith our computer experts in another office /
In filing cabinets
This information may be stored for
a long time even after you have stopped using Brent Mencap services /
I ………………………………………………………………………………
Agree to information about me being used in this way
Signed………………………………
Date………………………………….