Date of Referral
Date of Birth
Street Address Line 2
Who do you live with?
Name of Parent/ Carer/ Keyworker/ Social Worker
Phone number of Carer
Level of English
Name of School/College
I will respect Staff and volunteers and listen to them
I will be friendly and respectful to everyone
I will respect the Club and look after equipment
I will not fight and won’t get involved if others fight
I will not bring or use drugs, alcohol or weapons
I will come here to have fun and help others have fun
I will help out and keep the Club clean and safe
I agree to:
Tick if you agree
Dost keeping my personal information safely and securely and contacting me about activities or services.
I understand that Dost needs some information to keep me and others safe and understand Dost will only share my information with others who need to know this - for example funders, or if I or someone else is at risk if Dost doesn’t share this info.
Ask to see the information that Dost has about me if I want to see this.
I am aware I don’t need to decide to share any personal information - although this may mean that I am unable to join in activities due to safety.
Dost will delete my information after a certain period of time.
Talk to Marian or other Dost staff, if I am not comfortable at any time during activities - so they can help me feel safe and secure
Receiving emergency medical treatment if my Carer is not available to answer and sharing my Carer’s details
Being filmed or photographed during activities.
I understand photos/film might be used to tell others about what Dost does.
If I don’t agree, Dost won’t use any images of me
Speaking to Staff if I want to make a complaint about something that happens at Dost
I understand that enjoying the actiivities and being safe means I need to follow the rules above
Should be Empty: