Phone:

01442 247675

Email:

admin@dacorummencap.org.uk

Gateway

Gateway Club

The Gateway Club meets on the first Tuesday of every month at Adeyfield Community Centre 7.15pm – 9.15pm.

It is led by a paid Activity Leader assisted by our trained and vetted Volunteers. We arrange various activities such as Games Nights, live bands, bingo, karaoke, fish & chips, parties and Theatre trips.

 
Gateway Club Members must also be members of Dacorum Mencap.
This costs £15 per year.

Member Application

Please complete this form as fully as possible.

Adults with learning disabilities who live in, or receive services in Dacorum may apply to join our schemes. If you are having difficulties filling this form in, please ask someone to help you. Please complete all the sections that apply, as fully as possible (continue on extra sheets if necessary), and return it to the Dacorum Mencap office. The information you provide is confidential and is only for use by Dacorum Mencap. All your information will be kept secure and is protected under the Data Protection Act 1998.

If you are completing this form yourself please fill in your information below, if you are completing this form for someone else, please complete their information here and then your information at the end of the form.

About You
Please attach a photograph of yourself here
About your learning disability:
About Your Doctor

One of our aims is to give unpaid carers a break, however we are not able to cater for everyone’s needs, some will have to attend with a carer.
Please note that we may have to charge your carer for some activities.

In case of emergency, who should we contact?

About Your Main Carer:
If yes, please provide details below, each one will need to fill in an equal opportunities form which can be found at the end of this form (This is statistical for purposes, which our funders ask for; it is not used to identify individuals).

About other professionals in your life:
About Your Health
About your medication
(Please note that we are unable to administer medication at activities)
Please list all regular medication that you take, and explain what they are for:

(Please note that members are all adults and therefore responsible for their own alcohol consumption)
About your behaviour
Every new member is risk assessed, so we need to know what the risks are. Please be honest when answering these questions, if you have challenging behaviour it doesn’t mean that you cannot join our schemes.
About your Independence
(Please note that transport between your home and the activity is the responsibility of your carer.)
Your Background
Thank you for letting us know all about you, if we are unclear about anything we will contact you.
Declaration

You must read and provide your consent to this section to complete your application.

I accept responsibility that I have provided to Dacorum Mencap information that is correct and to the best of my knowledge. I understand that any changes of information should be given to Dacorum Mencap in writing and it is my responsibility to do so.

I give consent for Dacorum Mencap to request and receive information about me from people mentioned in this form as well as the following people who know me: Day service, Activity group, School, College, Charity or other organisation; Social Worker; Community Nurse; Doctor; Probation Officer; Support Worker; Employer.



If the person applying is unable to sign this form (or lacks capacity to give consent), please sign your consent for them:

Equal Opportunities Monitoring (about You)

This information is used for statistical purposes and not to identify specific individuals.
Equal Opportunities Monitoring about your Unpaid Carers

This information is used for statistical purposes and not to identify specific individuals.n
Unpaid Carer 1
Equal Opportunities Monitoring about your Unpaid Carers

This information is used for statistical purposes and not to identify specific individuals.n
Unpaid Carer 2
ANNUAL SUBSCRIPTION FOR DACORUM MENCAP

Membership to Dacorum Mencap is just £10 per year (April to April) for a family living at the same address. For this you get a say in how Dacorum Mencap is run, regular newsletters and information about what is happening locally.
Please send the completed form and your payment to:

Dacorum Mencap, 48 High Street, Hemel Hempstead, Herts. HP1 3AF.
Cheques payable to “Dacorum Mencap”


Please Clearly write your name and address on the back of the cheque

DATA PROTECTION ACT

All Information held on our computer is protected under the Data Protection Act.
Gift Aid declaration

Only to be completed by British Tax Payers
Name of charity DACORUM MENCAP (Charity Number 212549)
Please treat all gifts of money that I have made in the past 6 years and all future gifts of money that I make from the date of this declaration as Gift Aid donations.
You must pay an amount of Income Tax and/or Capital Gains Tax for each tax year (6 April one year to 5 April the next) that is at least equal to the amount of tax that the charity or Community Amateur Sports Club will reclaim on your gifts for that tax year. I understand that other taxes such as VAT and Council Tax do not qualify.
Your details
Please notify us if you:
1. Want to cancel this declaration.
2. Change your name or home address.
3. No longer pay sufficient tax on your income and/or capital gains.
What we can claim:
- We can reclaim 28p of tax on every £1 you gave up to 5 April 2008.
- We can reclaim 25p of tax on every £1 you give on or after 6 April 2008.
- The Government will pay us an additional 3p on every £1 you give between 6 April 2008 and 5 April 2011. This transitional relief for us does not affect your personal tax position.

If you pay income tax at the higher rate, you must include all your Gift Aid donations on your Self-Assessment tax return if you want to receive the additional tax relief due to you.

Thank you very much for taking the time to complete this declaration
Thank You for Completing our Form

We Will Be in Touch Soon