Full Name of young person (aged 13-19 years only)
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Age of young person
*
Please Select
13
14
15
16
17
18
19
Young person phone number (whatsapp number if possible)
*
Format: (000) 000-00000.
Sex/ identity
*
Please Select
Male
Female
Transgender
Other
Address
Street Address
Street Address Line 2
City
Post code
Young person Country
*
Please Select
Albania
Afghanistan
Sudan
South Sudan
Ethiopia
Eritrea
Vietnam
Iran
Iraq
Syria
Gambia
Somalia
Yemen
Libya
Egypt
Kuwait
Saudi Arabia
Morocco
Bangladesh
Pakistan
India
Senegal
Guinea
Other country (write below)
Other Country
Language
*
Please Select
Arabic
Tigrinya
Amharic
Oromo
Vietnamese
Somali
Pashtu
Dari
Farsi
Sorani
English
Albanian
Spanish
French
Wollof
Kurmanji
Other (please write below)
Other Language
Level of English
*
Please Select
None
Basic (Entry 1)
Intermediate (Entry 2)
Advanced (Entry 3 or above)
Who do you live with?
*
Own family
Foster Carer
Supported House
Non-supported House
Alone
With Friends
Hotel/Hostel
Homeless
When did you come to the UK?
*
Please Select
1 month - 3 months
4 months - 6 months
6 months - 9 months
10 months - 12 months
More than 1 year
More than 3 years
Do you go to school/ college?
*
Please Select
Yes - school
Yes - college
No
Name of school/ college?
Do you have health problems?
*
Please Select
No - I am fine
Yes - please write below
Health Details
Do you have a Social Worker?
*
Please Select
Yes
No
I don't know
Do you have a Solicitor?
*
Please Select
Yes
No
I don't know
Name of Parent/ Carer/ Keyworker/ Social Worker
Phone number of Carer
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RESPECT!!!
*
Rows
Agree
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:
*
Rows
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
Receive emergency medical treatment if my Carer is not available to answer and to share 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
Signature
Submit
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