the greenhouse Application form
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NAME OF PARTICIPANT
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ADDRESS |
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TELEPHONE
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EMERGENCY CONTACT NAME RELATIONSHIP
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ADDRESS
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TELEPHONE day evening mobile |
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MEDICAL INFORMATION
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Date of birth |
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yes/no |
If yes please give brief details |
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Are you currently receiving medical treatment?
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Have you been given specific medical advice to follow in an emergency? |
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Do you have any allergies to food or medicine which we should be aware of?
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please give details of disability, illness or injury
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adhd |
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asthma, bronchitis |
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autism |
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axial instability |
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challenging behaviour |
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diabetes |
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epilepsy, fits or fainting |
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heart condition |
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learning disability |
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muscle weakness |
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physical disability |
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sensory impairment |
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other (please specify) |
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If you have ticked any of the above boxes please give us more details
Tell us about yourself, what you are good at, what you enjoy, what you need a little help with, what you need a lot of help with, things that cheer you up, things that upset you. The more you tell us the better we’ll be able to plan to meet your needs.
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CONSENT
I have given full medical details.
I consider that I am capable of participating in the activities.
In the event of illness or accident I give my consent to any necessary medical treatment.
We sometimes take photographs for educational or display purposes
I don’t mind having my picture taken I don’t want to have my picture taken
PREFERRED DAY(S)
MONDAY c TUESDAY c FRIDAY c
FARM DAY: WEDNESDAY c
Signed date
Please complete and return to qe2centre@aol.com
or
the greenhouse
QE2 Activity Centre
Manor Farm Country Park
Pylands Lane
Bursledon
Hampshire
SO31 1BH