MADE-WELL'S PARTICIPATION FORM

PARTICIPANT FORM
We're so happy to welcome you to Made-Well! This form helps us get to know you, understand how we can support you, and make sure you feel safe, comfortable, and included in everything we do. If you need help filling it in, please just ask - we're always here to help.
Your Full Name*
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Photo of yourself (optional) 3MB limit

Cancelof
Main Contact Name*
Relationship to You
Phone Number*
Alternate Number
Email
example@example.com
Emergency Contact Name (if different)
Relationship to You
Address
Phone Number
Email
example@example.com
Your Doctors Name
Surgery Address
Telephone Number

Area CodePhone Number
Email if known
example@example.com
Please let us know about any regular medications, allergies, or emergency meds you use. While we can't give out medication, we can help remind you to take it.
Medications and any side effects
Emergency medications e.g. for epilepsy or allergies
Allergies and how they affect you
Any health issues that may affect activities
Do you wear a medic-alert

YesNo
Do you have a risk assessment or support plan we should be aware of
Do you have any additional needs, communication preferences, or anything else that could help us support you better?
What would you like to do at Made-Well? (Tick as many as you like)

Gardening/HorticultureCooking/BakingCraftsAnimal CareWoodworkOther
What would you like to get out of coming to Made-Well eg new skills, confidence, fun, meeting people, volunteering
How will you attend

On my ownWith support
Do you need

1:1 support from your own carer1:1 support from Made-Well (charges apply)I'm fine in small groups
Please tell us a bit about what you like to do at home or in the community - any hobbies, things that you do to relax, things you do or like doing with family members or friends
Any life interests that we could explore with you here at Made-Well
Your Signature*

Clear
Date*

MonthDayYear
If someone else is filling this in for you
Name
Relationship to Participant
To be filled in by a parent/guardian if the participant is under 18.

I give permission for my child to attend Made-Well.

I confirm all medical info is accurate.

I understand that Made-Well is not responsible for injury/loss unless due to negligence.
ParentGuardian Signature

Clear
Date

MonthDayYear
How will you pay for the sessions?*

Direct DebitInvoiceFundedPay on the DayOther
Billing Contact (if different)
Organisation (if any)
Address
Phone

Area CodePhone Number
Email
example@example.com
Send invoice by

EmailPost
Photography Permission

We love to share what we do at Made-Well through photos, but only with your permission. Please sign below if you give it.

I give permission for my photo to be used for Made-Well's promotion (e.g. website, social media). I understand I won't be paid or asked for approval of every image.
Signature

Clear
Printed Name
Date

MonthDayYear
What Happens Next?

1.Once we receive your form, a member of the team will contact you to arrange your first visit.

2.You'll receive a friendly welcome and short induction on your first day. 3.If you have any support needs, we'll work with you to make sure they're in place before you begin.

4.We'll check in regularly to make sure you're happy, safe, and getting the most out of your time with us!

If you have any questions at all, please feel free to call us on 01837 810584 or email us at staff@made-well.co.uk

If you require this form in a different format please speak to us.
Company Number: 06386837

Registered Office: Made-Well, West Fishleigh Farm, Hatherleigh, Okehampton, Devon, EX20 3QA. A Community Interest Company limited by guarantee.
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PARTICIPANT FORM