Virtual Services Access Form
Service User Name
*
First Name
Last Name
Service User Address
*
Street Address
Postcode
Contact Telephone Number
E-mail Address
*
Next of Kin (Emergency Contact)
First Name
Last Name
Next of Kin Telephone (Emergency Number)
How would you (the service user) describe your gender?
Male
Female
Prefer not to say
Other (prefer to self describe)
Please confirm you (the service user) is over the age of 18?
Yes
No, I am under the age of 18
Do you currently live
At home with Parent/carers
In supported living
In a residential setting
Unsupported in my own home
Current Day Service Provider(s):
Please list which Virtual session(s) you (the service user) would like to join below:
Do you (the service user) have access to an electronic device i.e. Computer/Tablet/Smartphone?
Yes
No
Other
Do you (the service user) have access to reliable internet?
Yes
No
Other
Have you (the service user) accessed zoom sessions before?
Yes
No
Other
Do you (the service user) require support to access zoom sessions?
Yes
No
Other
If yes please tell us about it here.
Is there anything you feel we should know about you (the service user's) required support, which may be relevant to accessing virtual sessions?
Yes
No
If yes, Please tell us more
Please use the box below to let us know of any known risks you (the service user) may have if engaging in certain activities. E.g. light sensitive epilepsy, challenging behaviour etc.
Are you currently taking any emergency medications? (eg. EpiPen, Asthma pump, Buccal Midazolam)
Do you (the service user) consent to a photo or short video clip that you may feature in being used promote virtual sessions?
Yes
No
Please upload your (the service user's) photo below (This is optional but will help services to identify new people in zoom sessions)
Upload a File
Drag and drop files here
Choose a file
Optional
Cancel
of
By signing the below I the service user or Parent/Carer of the service user consent to the above information being shared across local service providers to enable me to access virtual services. I understand that I can request a copy of Radiomarathon's GDPR privacy policy at any time for further information on collection and use of my personal data.
Submit
Should be Empty: