/

Sibling Support Group Registration Form

Contact Details

Name of Member: D.O.B:

Address:

Tel No:Mobile No:

Today’s Date: Email address:

For every family who uses a Leeds Mencap service, one family member must become an Associate Member or Full Member. You can become an Associate Member at a cost of £1 or a Full Member for £12 per annum.

Please tick the box if you have already become an Associate/Full Member.

If you have not yet become a member then please contact Lucy on 0113 2351331 or email

EMERGENCY CONTACT

Name:

Tel No: Relationship:

(Parent/Grandparent etc.)

Londesboro Terrace

East End Park

Leeds

LS9 9NE

Phone: 0113 2351331

Fax: 0113 2496006

email:

Eligibility for Siblings Support Group

Name of Sibling (with disability)

Sibling’s date of birth

Does the siblings currently use any targeted Short Breaks? Yes/No

Which service/s so they access? Such as Leeds Mencap youth club, playscheme or Me2or services from other providers

Information about the family. Include information about parents/carers and siblings and the impact of having a disabled sibling on the child/young person who is applying to join the Siblings Support Group.

Medical & Other Details

Does your child have any medical needs?

YESNO

If yes, please provide details

Does your child have any allergies?

YESNO

If YES, please tell us what you are allergic to, for example nuts and what food and drink you are not allowed. Please also give an indication of the likely reaction to exposure and the action we should take:

Is there anything else we should know for attendance at the Club? For example:

  • Medication being taken, which in the case of an emergency, we could pass this information on to the emergency services?
  • Other medical conditions which you feel we should be aware of?
  • Any behavioural or emotional needs (anxiety, low mood, aggression etc)?
  • Any other special educational needs, disability, impairment or communication requirements you would like us to be aware of:

Please indicate using the table below what you hope your child will get from attending the Siblings Support Group:

Meet other siblings
Have fun
Learn more about disabilities
Learn how to get on better with brother or sister
Learn how to get on better with mum/ dad/ carers
Learn how to cope better with difficult times
Have a break from home
Take part in new things

Please read the statement below, sign and date.

  • I certify that the information given on this form is correct.
  • I give permission to any emergency treatment deemed necessary by a medical professional. I therefore authorise the Leader or Assistant Leader to sign on my behalf any written forms of consent required by hospital authorities should a delay to obtain my signature be considered, in the opinion of the doctor or surgeon concerned, likely to endanger my health or safety.
  • I understand that whilst every care will be taken by the organisers, they cannot be held responsible for incidents arising out of the unreasonable behaviour of myself or others, nor for the loss or damage to personal property.
  • I also agree that the Club can share the information, on a need to know basis, to ensure that I am as adequately supported as possible, during Club hours.
  • Please circle if you do not give permission for Leeds Mencap to share information provided with Leeds City Council for monitoring purposes. NO

Signed: Date:

We need to provide the information on this page to ensure the service continues to run.

Equal Opportunities

Please fill out the next section in order to show diversity and fairness of our selection methods for playscheme. Any information you provide will be kept confidential.

Please tick

White British
White Irish
Traveller of Irish Heritage
Any other White background
Gypsy/Roma
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed background
Indian
Pakistani
Bangladeshi
Any other Asian background
Caribbean
African
Any other Black background
Chinese
Any other ethnic group
Refused

Photography/Filming consent form

Please PRINT

Name of person to be photographed/filmed:

This person is a:

Service user / X / which service? / Siblings
Parent/guardian/family member of service user / which service?
Leeds Mencap employee
Leeds Mencap volunteer
Other / please specify:

It has been explained to me that Leeds Mencap requires photographs, voice and video recordings in order to show a positive view of the organisation, its employees, volunteers and people that use its services.

I consent to all future collection, storage and use of photography, video and voice recordings of the above named person from the date stated below.

I understand that any images or recordings may be used by Leeds Mencap at any time, both now and in the future, including on promotional materials, website, and social media.

I accept that I will not be paid or be provided with a different service by Leeds Mencap or its partners as a result of being involved in recordings or photography. I will not own the copyright.

By signing this consent form I agree to all of the above.

Name of consent-giver:

Contact phone/email:

Sign:Date: