Involve Active Service User Application Form

Service User Application Form
What sessions are you interested in?*

S.T.E.P. programme (16+ weekdays 10am-3pm)BeeReady programme (16+ weekdays 10am-3pm)School Holiday Activites (8+)Get2Gether Social activities (8+)Family Fun days (accompanied by parent/guardian)Other
Where did you hear about INVOLVE ?*
Service User Name*

First NameLast Name
Service User Date of Birth*

MonthDayYear
Date
Gender and preferred pronouns*
School/College
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name*
Parent/Guardian Email address*
example@example.com
Parent/Guardian Phone Number*

Area CodePhone Number
Parent/Guardian Mobile Number*

Area CodePhone Number
Parent/Guardian Address if different from above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address for Invoices to be sent to*
example@example.com
Emergency Contacts (please complete 2 contacts, 1 can be the same details as above)
Emergency Name & relationship to service user*

Primary contactContact 2
Emergency Phone Number - Primary contact*

Area CodePhone Number
Emergency Phone Number - contact 2

Area CodePhone Number
Emergency contact Address*

Primary contact

Contact 2 address

CityState / Province

Postal / Zip Code
Medical Information

The information given may be vital in an emergency. It will remain confidential but may be given to a third party in the event of an emergency e.g. emergency services staff.
Doctor's Name & Surgery*
Please tick if the service user has any of the following:*

EpilepsyCerebal PalsyMobility DifficultiesDiabetes Type 1 or 2Learning DisabilityAutism Spectrum DisorderSpeech difficultiesHeart ConditionsEpilepsyAny other medical conditions, please explain belowNone
If you have ticked any of the boxes please give further information here
Please list any food intolerances or allergies i.e. hay fever, penicillin etc.
Service User medication....Please give details of all medication including doses and who normally administers the medication
Is there any medication that might be required in an emergency? If "Yes', please state:
Optional - Please tell us the service users ethnic origin (this is purely for statistical reasons for our funders)
If other selected, please describe below
Drop off and pick up
Please give the names of any person who is authorised to collect the service user
Please give a password that we can use to clarify identity of someone collecting if not listed above*
How will the service user be collected from Involve*

CarTaxiWalkBikeIndependent
Are you/service user a member of Activities Unlimited?*

YesNo
If YES please state your Activities Unlimited ID NUMBER
Does the service user have an EHCP plan?*

YesNo
If yes, what is the review date

MonthDayYear
Date
Does the service user have a Social Care personal budget agreed by a social worker? If yes, please select the issuing authority?

Suffolk County CouncilNorfolk County Council
Parent/Carer Evaluation
On a scale of 1-5 (where 5 is high) what level do you feel the service user is at in the following areas:
Family Relationships

1

2

3

4

5

1 is Worst, 5 is Best
Communication

1

2

3

4

5

1 is Worst, 5 is Best
Learning new skills

1

2

3

4

5

1 is Worst, 5 is Best
Staying Healthy

1

2

3

4

5

1 is Worst, 5 is Best
Gaining Qualifications

1

2

3

4

5

1 is Worst, 5 is Best
Independence

1

2

3

4

5

1 is Worst, 5 is Best
Confidence/Self Esteem

1

2

3

4

5

1 is Worst, 5 is Best
Positive Behaviour

1

2

3

4

5

1 is Worst, 5 is Best
Understanding risks

1

2

3

4

5

1 is Worst, 5 is Best
Thinking about progression... What is the most important thing for the service user to achieve from Involve e.g. having fun, respite, socialising, level of care and support offered etc.
Is there anything here at Involve that we don't offer that you think would be good for us to offer in the future?
CONSENT FOR OFF SITE ACTIVITIES

Please sign and date the form below if you are happy for your child:

a) To take part in trips and other activities that take place outside of The Involve Centre premises; and

b) To be given first aid or urgent medical treatment during any trip or activity.

Please note the following important information before agreeing this form:

The trips and activities covered by this consent include; all visits outside of The Involve Centre building. We may not send out information about each trip or activity before it takes place.

You can, if you wish, inform us that you do not want your child to take part in any particular trip or activity.

Please note that on the day of an off-site activity The Involve Centre will be closed during that session.

Written parental consent will not be requested from you for the majority of off-site activities offered by Involve Active which take place during the normal session times. We will not request further consent should these activities take part outside of session times, but we will inform you in writing in advance.

Please complete the sections below, and sign and date if you agree to the above.
Please note below details of any medical condition that the named suffers from and any medication that should be taken during off-site visits. Please also detail any other relevant information e.g. fear of dogs, loud noises etc.
I consent to the service user named on this form attending off-site activities*

YesNo (if no please give further information below)
If no, please explain below your reasons so that we can see if we are able to help the service user attend these trips
Signed*

Clear
Date*

MonthDayYear
Date
Consent to Process Personal Data
We use the information you share with us in three ways;

Firstly, to enable us to provide a person centred service and to promote health, wellbeing and safeguarding, and to secure payment for the services we provide where appropriate.

Secondly, to enable us to collect information to help us to improve our services, develop the programmes that we provide and help us to seek funding for services.

Thirdly, to enable us to send you information about events, fundraising and new programmes we are running or involved with.

For full details of our how we collect, store, share and manage your personal data please see our Privacy Notice

Consent Rules

Involve Active Ltd. would like consent to process the personal data you share with us as follows:
Service User Name*
I consent to the use and storage of my personal data by Involve Active Ltd to enable them to provide a person centred service and to promote health, wellbeing and safeguarding, and to secure payment for the services we provide where appropriate.*

YesNo
I consent to the use and storage of my personal data by Involve Active (once anonymised) for statistical purposes.*

YesNo
I consent to the use and storage of my personal data by Involve Active Ltd. in order that I might receive newsletters and information about events, workshops and customer surveys.*

YesNo
Photographs & Videos

To help us provide a safe environment for people coming to our activities, anyone wanting to take photographs or videos at INVOLVE must ask permission before doing this.
INVOLVE may take pictures or videos for use in future publicity or promotional material. Do you give consent for the person specified above to be used in this way?*

YesNo
INVOLVE may take pictures or videos for use on our web page. Do you give consent for photos/videos of the person specified on this form in this way?*

YesNo
INVOLVE may take pictures or videos for use on our social media. Do you give consent for photos/videos of the person specified on this form in this way?*

YesNo
INVOLVE may receive requests from 3rd parties (funders) who wish to use our pictures or videos for use in their publicity/promotion, on their webpage or for their social media. Do you give consent for photos/videos of the person specified on this form in this way?*

YesNo
I understand that I can withdraw my consent to one or more of the above at any time by contacting Involve Active Ltd
Date*

MonthDayYear
Date
Communication and Consent for Personal Care
Does the service user require personal care? (if yes please complete the sections below)*

YesNo
a) My young person will communicate using: (Taking advice from parents/carers where necessary, state he way in which the Service User is best able to communicate with staff e.g. words/signs/communication book/communication aid/body movements etc:- If appropriate please complete the following:- b) When I need to go to the toilet I will say or do :-
What is the best way for the service user to communicate with staff? e.g. words/sign/communication book/body movements etc.
When I need changing I will:
Additional information we need to be aware of:
I agree for staff at Involve to complete personal care as needed on the service user named on this form.
Parent/carer or Service User signature and date

Clear
OFFICE USE ONLY

At INVOLVE my Personal Care Team are:-

The Personal Care needs for the above named individual have been identified by INVOLVE and appropriate methods of communication have been identified. I am happy for these to be carried out at INVOLVE
INVOLVE Staff signature

Clear
ALL ABOUT ME!
What people like and admire about me.... e.g. qualities and strengths*
What is important to me? e.g. What hobbies/activities do you like, important routines, What people need to know and do in certain situations, Family circle*
How to support me.. e.g. Who is important, what action should be taken if I am anxious*
If you would like to add any documents that you feel will helps us in supporting such as previous care plans etc. Please upload here.

Cancelof
Service User signature.*

Clear
Should be Empty:

Service User Application Form

Drop off and pick up

Parent/Carer Evaluation

Consent to Process Personal Data

Communication and Consent for Personal Care

ALL ABOUT ME!