Transitions 2008

Booking Form

Sunday August 3^th – Friday August 15^th  

Part One 

NAME OF PARTICIPANT           ..................................................................................

 ADDRESS                             ..................................................................................

                                          .................................................................................. 

                                          .................................................................................. 

                                          ....................................            POSTCODE....................

                                          TEL  ............................            e mail  ..........................

DATE OF BIRTH                    …………                                   AGE on August 3rd …………             

EMERGENCY CONTACT

NAME                                 ..................................................         

RELATIONSHIP                    ........................                                

 ADDRESS                             ..................................................................................

                                          .................................................................................. 

                                          .................................................................................. 

                                          ....................................            POSTCODE....................

TELEPHONE                         ..............................................(day)       ..........................(evening)

MOBILE                               ................................................

Part Two

MEDICAL INFORMATION

Are you currently receiving medical treatment?                                                         yes/no

           If yes please give brief details

Have you been given specific medical advice to follow in an emergency?                yes/no

            If yes please give details

Do you have any allergies to food or medicine which we should be aware of?         yes/no

            If yes please give details

Please give details overleaf of disability, illness or injury

     asthma                        c     axial instability            c        bronchitis                    c

    challenging behaviour    c     diabetes                     c        epilepsy                      c  

              fits or fainting               c      heart condition            c      learning disability        c

              muscle weakness       c        physical disability        c       sensory impairment    c

              other (please specify) c

Part Three

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 that you can tell us the better we’ll be able to plan to meet your needs.  (write as much as you want to)

Part Four

CONSENT FORM

CONSENT

I have given full medical details.  

I consider that I am capable of participating in the activities organised by the Centre. 

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

c I don’t mind having my picture taken     c I don’t want to have my picture taken

Signed              ...............................................   (participant over 18)

Signed              ...............................................   (parent/guardian if participant under 18)