Board and Computer Games Drop In Consent Form

Board and Computer Games Drop In Consent Form
Participant Information:
Name

First NameLast Name
Mobile Phone Number
Please enter a valid phone number.Format: (00000 000 000).
Borough residing in:
Please note that these sessions are only for residents residing in Richmond upon Thames and Hounslow.
Session Information:
1. Are you able to get up a flight of stairs? (we are situated on the first floor)
2. Will you be bringing a carer or Personal Assistant?
3. Do you have any requirements or additional needs that we should be aware of so we can support you in these sessions?
If yes, please specify:
4. Do you have any food allergies or intolerances?
If yes, please specify: We will try best to accommodate this.
5. Do you consent for you to be photographed?
Additional Information:
Age group:
Ethnicity:
Please specify if you are from any other ethnic background:
Where did you hear about us:
Consent:
I hereby give my consent to participate in the Board and Computer Games Drop In sessions and acknowledge that I understand the information provided above. I understand that I am required to attend all sessions.
Signature:
Date

DayMonthYear
Thank you for your co-operation! We hope that you look forward to our games sessions!
Date

DayMonthYear
Date
Should be Empty:

Participant Information: