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.

Title

MR MRS Miss MS

Please attach a photograph of yourself here

Do you give us permission to use photographs of you in publicity, newsletters, displays, social media etc.?

Yes No

About your learning disability:

Do you have a diagnosis of a learning disability?

Yes No

What is your diagnosis?

When did you receive your diagnosis?

Who gave you your diagnosis?

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.

Are you planning to attend with your own carer?

Yes No

If yes, for what reason?

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:

Do you receive any support from family members or friends?

Yes No

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:

Do you have a current social worker?

Yes No

If yes, what is their name?

Which team are they from?

Do you have a current community nurse or probation officer?

Yes No

If yes, please give their name and contact details:

Do you attend any other services or clubs?

Yes No

If yes, please give their name and contact details:

Do you have a voluntary job or paid employment?

Yes No

If yes, please give their name and contact details:

Do you have epilepsy?

Yes No

If yes, how often do you have a seizure?

What type of seizures do you have?

Do you get a warning?

Do you have an epilepsy protocol?

Yes No

If Yes please provide a copy (Scanned Image or PDF)

Do you have any of the following

Asthma Diabetes Mental Illness

If you have a mental illness, what is your diagnosis?

How does this affect your life? (tell us about any phobias, anxieties, eating disorders or behaviours that we need to be aware of)

Do you have any allergies?

Yes No

If yes, what are you allergic to?

Do you have any special dietary requirements?

Yes No

If yes, what are they? Is this medical, cultural or choice? Please explain

Do you need any help with feeding?

Yes No

(Please note that we are unable to help with feeding, except to remind people to eat and drink)
If yes, please explain

Do you have any other medical conditions that we should be aware of?

Yes No

If yes, what are they?

Do you have any sight, hearing or mobility problems?

Yes No

If yes, what are they?

Do you have any incontinence problems?

Yes No

If yes, please explain

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:

Do you have any incontinence problems?

Yes No

Is there anything else we need to know about your health?

Yes No

If yes, please explain

Do you consume alcohol?

Yes No

(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.

Do you show any aggression or challenging behaviour (this includes abusive language and sexual behaviours)?

Yes No

If yes, please explain

Are you likely to wander off, hide or leave without telling anyone?

Yes No

If yes, please explain

Are you likely to be over friendly, tactile or flirty with other people, including strangers?

Yes No

If yes, please explain

Are you aware of and do you respect other people’s boundaries and personal space?

Yes No

Have you ever posed a risk to others due to your behaviour?

Yes No

If yes, please explain

About your Independence

Are you an independent traveller during the day?

Yes No

Are you an independent traveller during the evening?

Yes No

If you were at an activity and wished to leave early, are you safe to do so?

Yes No

(Please note that transport between your home and the activity is the responsibility of your carer.)

Are you fully aware of road safety and able to cross roads on your own?

Yes No

Are you aware of the value of money and able to use money without assistance?

Yes No

Do you have any speech difficulties?

Yes No

If yes, please explain

Do you use any other forms of communication? Eg. Makaton, symbols, speech box

Yes No

If yes, please explain

If you are under 30, please let us know which schools and colleges you attended

If you have recently moved from another area, please let us know where you have moved from (include the date of your move)

Use this space to tell us about anything else you feel we should know about you, you could include such things as cultural or religious information; the best way to handle you if you become unhappy; any involvement with the police or anything else that is relevant to your application.

Thank you for letting us know all about you, if we are unclear about anything we will contact you.

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.

Consent

By clicking this box I am effectively digitally signing this form and providing my consent for Dacorum Mencap to use the Information for my membership application

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

Consent on behalf of applicant

By clicking this box You are effectively digitally signing this form and providing your consent for Dacorum Mencap to use the Information for my membership application on behalf of the applicant

Relationship to applicant

Name of person who completed the form

If anyone else was present when the form was completed, please also add their names

Equal Opportunities Monitoring (about You)

This information is used for statistical purposes and not to identify specific individuals.

Do you have a disability?

Equal Opportunities Monitoring about your Unpaid Carers

This information is used for statistical purposes and not to identify specific individuals.n

Do you have a disability?

Equal Opportunities Monitoring about your Unpaid Carers

This information is used for statistical purposes and not to identify specific individuals.n

Do you have a disability?

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

Title

MR MRS Miss Ms

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

Phone:

Email:

Out & About TOGETHER