Made-Well's Taster Day Form

MADE-WELL

A Community Interest Company
Taster Day Form
We're so pleased you're joining us for a Taster Day. This form helps us get to know you better and make sure your time with us is safe, enjoyable, and tailored to your needs. Please complete this form and return it to staff@made-well.co.uk or our reception.
1. Participant's Full Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone

Area CodePhone Number
Email
example@example.com
2. Emergency Contact Name
Relationship
Phone

Area CodePhone Number
Email
example@example.com
Address
3. Health conditions disabilities or diagnoses
Allergies
Medication
Dietary needs
Support required (mobility, communication etc)
4. GP Name
Surgery
Phone number

Area CodePhone Number
5. Interests - What would you like to do at Made-Well (e.g. animal care, gardening, crafts, cooking, socialising):
6 Is there something you would like to do that you don't think we offer?
7. Consent (please tick)
Signed
Name if signing for participant
Relationship
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
If you require this form in a different format please speak to us.
Date Received

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Staff Member
01837 810584 staff@made-well.co.uk

Company Number: 06386837

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

MADE-WELL

Taster Day Form