Membership Form

Personal Information

Personal Information - Section 1

Full Name

Personal Information - Section 2

Street

Town

County

Postcode

Personal Infomation - Section 3

Date of Birth

Personal Information - Section 4

Primary Phone Number

Other Phone Number

Personal Information - Section 5

Email Address

Repeat to confirm

Emergency Contacts (2 Required)

Emergency Contact 1

Name

Telephone Number

Relationship to you

Emergency Contact 2

Name

Telephone Number

Relationship to you

About You

Do you have a learning disability or autism?
Yes No

If Yes, please specify

Do you usually need help with any personal care? (e.g. help visiting the bathroom)
Yes No

If Yes, please specify

Do you experience seizures, absences or blackouts?
Yes No

If Yes, please specify

Do you have any allergies?
Yes No

If Yes, how do you manage these. What do we need to do to keep you safe? (Do you carry an EpiPen) if so, where do you keep it?

Do you have any special dietary requirements?
Yes No

If Yes, please specify

Do you have any medical conditions we need to be aware of?
Yes No

If Yes, please specify

Do you have trouble concentrating?
Yes No

If Yes, what makes things easier for you to concentrate?

Are there any situations where you don’t feel very confident?
Yes No

If Yes, please specify

Do you have challenges getting around daily?
Yes No

If Yes, please specify

Do you feel angry or frustrated?
Yes No

If Yes, what can make you feel angry and how might this effect how you act?

Do you feel worried?
Yes No

If Yes, when you’re feeling worried how do you deal with it?

Do you have any fears and or phobias?
Yes No

If Yes, please specify

Enjoy & Achieve

Enjoy & Achieve - Section 1

At which location(s) are you interested in attending activities?

Handforth

Macclesfield

Poynton

Sandbach

What type of activities are you interested in?

Arts & Crafts

Drama

Food & Drink

Keeping Active

Media

Health & Wellbeing

Social Activities

Social Enterprise

Together Time

Trips Out

Other

If Other, please specify

Do you have any hobbies or interests. What do you enjoy doing in your spare time?

Do you have any personal goals or ambitions?

Make friends

Have fun

Get active

Build confidence

Have more of a say

Learn a new skill(s)

Support my own wellbeing

Be more independent

Not sure yet

Other

If Other, please specify

Enjoy & Achieve - Section 2

Can we ask about how you feel in some situations? On a scale of 1 to 5, where 1 means you find it difficult and 5 you find it easy (1 2 3 4 5).

Meeting new people

Waiting to take your turn in a queue

Starting or joining a conversation

Sharing things

Winning and losing

Following instructions

Listening to other people

Being in a group of people

Respecting personal space

Enjoy & Achieve - Section 3

How do you communicate (let others know what you want) (E.g. Speech, pictures, signing; pointing)

What’s the best way for others to communicate with you?

How would others know that you are not enjoying yourself?

Do you have beliefs and/or values you would wish us to consider and respect?

Enjoy & Achieve - Section 4

Will you attend sessions alone or with support?
Alone With support

Do you need help to manage your own money?
Yes No

Can you leave sessions on your own, or would you prefer for us to wait with you until someone you know meets you?
On my own Prefer someone to wait with me

Enjoy & Achieve - Section 5

Where did you hear about us?
Event Family Flyer Friend Other Organisation Social Worker Website Word of mouth

Do you have a social worker?
Yes No

Agreements

Media Consent: At times we use members images. We must ask you permission if its ok for us take and use any images of you.

I agree to being photographed during sessions or other social activities
Yes No

I agree to being filmed during sessions or other social activities
Yes No

I am happy for group pictures that I am in to be shared on the Time out Group website and other social media channels to promote the charity
Yes No

I am happy for my image to be used on Time Out Group Marketing materials
Yes No

Confirmation

I/We confirm that the information given is correct to the best of my knowledge and belief

I/We agree to advise Time Out Group if there are any changes to the information given

I/We understand the information given will be used to carry out any risk assessments

I/We understand the information given will be shared with Time Out Group staff and volunteers, who have signed a confidentiality agreement

I/We understand the information about me is kept securely in accordance with data protection regulations (GDPR)

I Agree to the above
Yes No

Name

Date

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Working together for greater independence

01625 520652

Working together for greater independence

 01625 520652