Your Information
Please provide details
First Name
Last Name
Date of Birth
Address
Email
Phone
Important / Medical Information
These questions are to determine if we need to make any adjustments in order for you to access our service, or anything we need to be aware of whilst you are with us. Please complete this section as thoroughly as possible. If required, we may need to discuss this section with you or ask you for further information.
Please provide details such as: How can we help / support you with this? What do we need to do if you have an issue with your medical condition or allergy whilst you are here? (E.G. If you require medical equipment, asthma inhaler, insulin dispenser etc. please tell us where you keep this and how to help you use it)
Please provide details such as: Will this affect you accessing our service? Is there anything we can do to support you with this? What are your triggers? What do we need to do if you have an issue with your mental health whilst you are here? (Mental Health issues could include depression, high anxiety, anger issues, OCD, phobias)
Please provide details. Please note any criminal record you have will be discussed with you and any risk is assessed. It will not automatically exclude you from undertaking any support within our service
Please provide details of the triggers and of how we can support you should you become distressed during a group.
Is there anything other information you would like us to know? For example, any sensory issues, history of vulnerability or absconding.
Photographs and Social Media
SKY Autism Support would like the permission to use images and/or video footage taken of the attendee, for the website and potential social media - solely for the purpose of raising awareness of the group and offering updates. Should you wish to view the photographs or videos, please ask by email or in person.
Declaration
I grant permission for photographs of the above child to be used in the formats indicated on this form.
Your Name
Emergency Contact Information
Emergency Contact 1 - Name
Emergency Contact 1 - Relationship to Attendee
Emergency Contact 1 - Contact Information
Emergency Contact 2 - Name
Emergency Contact 2 - Relationship to Attendee
Emergency Contact 2 - Contact Information
The information that I have provided is correct to the best of my knowledge. I understand that this information will be used only for the purposes of me accessing the SKY groups. I understand that my details will be stored securely and in accordance with the confidentiality and data protection policies of SKY Autism Support.
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