COAM Wellbeing Activities 2024 - Self-registration Form

CHILTERN OPEN AIR MUSEUM

Wellbeing Activities 2024 Self-Registration Form
Please complete as many parts of this form as you can and then select 'Submit' at the end. A member of the Museum's staff will contact you on receipt of this form to confirm arrangements, to discuss dates and transport options, and to answer any questions you may have.

Personal information will be treated with confidentiality and on a need-to-know basis. We will not forward personal details to any other organisation.
I am interested in (please select one or both):

Accompanied WalksSummer Wellbeing Socials
Your Name

TitleFirst NameSurname
Address
Postcode
Tel
Email
example@example.com
D.O.B
GP Name
GP Surgery
Please comment on the following if you think relevant or useful for us to know.
Your mobility, eg do you use a wheelchair or walking aid?
Any medical information or history, eg to do with seizures, hearing, sight?
Do you have any food intolerances or allergies?

YesNo
If yes, please provide details
Please provide some general information about yourself, e.g. likes/dislikes, interests and skills.
Please provide details for one to two other contacts or professionals involved in your well-being e.g. carer or family member. One of these people may accompany you at the Museum.
Contact 1

TitleFirst NameSurname
Relationship to you / Job Title
Tel
Email
example@example.com
Would you like this person to accompany you at the Museum?

YesNo
Contact 2

TitleFirst NameSurname
Relationship to you / Job Title
Tel
Email
example@example.com
Would you like this person to accompany you at the Museum?

YesNo
In the unlikely case of an emergency, I consent for the Museum to contact the above people involved in my well-being.

YesNo
I consent to any recording/filming/photography for training purposes, presentations, funding applications, project reports and publicity:

YesNo
Your Name
Signed

Clear
Date

MonthDayYear
Date
Should be Empty:

CHILTERN OPEN AIR MUSEUM