Autumn 2019 Hackney Shed Registration form

Hackney Shed Collective Registration Form

To work with you we need some information. This information is important so we know how to contact you and what your needs are.
ALL DETAILS WILL BE TREATED AS STRICTLY CONFIDENTIAL

FOR ALL MEMBERS UNDER THE AGE OF 18 A PARENT OR CARER MUST SIGN THE FORM
Please fill in all the blank boxes in this form

We can provide easy read forms to be printed and then scanned/ brought on day of the workshop - if you would prefer an easy read form please let us know

If you need support filling in this form please contact us:
Phone: 07927 082 592

Email: anna@hackneyshed.org.uk

vicki@hackneyshed.org.uk

Please be aware we are all part time and it may take us a few days to respond to you
Participants details
Name *

First Name Last Name
Date of birth *

Day Month Year
Please put a '-' between day/month/year. For example 23-10-2018 Date Picker Icon
Gender *
Ethnicity *
Phone number (of participant if you have one)
Email (of participant if you have one)
example@example.com

Address *

If we need to get in touch with you about the workshops who would you like us to contact? *

Contact me Contact someone else
If you would like us to contact someone else who should that be?
Name, relationship to you, contact number and email
Which weekend will you be coming to? *

5th and 6th October 16th and 17th November Both
Are you in education or working or neither? *

Full time education Part time education Full time work (paid) Part time work (paid) Not in education or working Volunteering or other unpaid work
Travel Information
Are you an independent traveller? *

Yes No Sometimes
Please tell us your travel arrangements for this workshop *
E.g. travelling independently or being collected
Is it ok for you to leave the session at lunch time? (if this is relevant)
Support Needs

The next questions are about your needs and how we can best support you. Knowing about your special educational needs or disabilities means we can help you better.

Physical and learning needs *

	Yes or no
Are you a wheelchair user?
Do you consider yourself to have a learning disability/ difficulty?
Do you have a visual impairment?
Do you have a hearing impairment?
Do you need support reading or writing?
Do you use Makaton?
Do you consider yourself to have a neuro-diversity (such as autism, ADHD, tourette syndrome or something else)?
Do you have any other support needs you think we should be aware of
Do you need to take extra breaks?
Do you need a BSL interpreter?

How can we best support you with these needs? Please feel free to use this box to tell us more about your needs if you would like to.

Emotional and wellbeing needs *

	Yes or no
Anxiety
Stress
Mental health needs
Is there anything in particular that can cause you to have a negative reaction?

Health and medical needs *

	No	Yes (if yes please give details)
Do you have any medical conditions?
Do you take any medication that we need to know about?
Do you have any allergies?

Will a support worker be coming with you? *

Yes, I will have a support worker with me in sessions I will attend sessions on my own
*Hackney Shed is unable to support with personal care or medication.
If you need support with any of this you will need to come to sessions with a support worker
Emergency Contacts

Please ensure that these are numbers we can ring if for any reason we need to contact anyone in an emergency during the session
Emergency contact one
Name *

First Name Last Name
Relationship to participant *
E.g. mum, dad, carer
Phone number *
Email
example@example.com
Emergency contact two
Name *

First Name Last Name
Relationship to participant *
E..g. grandparent, neighbour
Phone number *
Email
example@example.com
Permissions

This section is asking you to say if you are happy for Hackney Shed to do different things

Permissions to use photographs or films *

	Yes or no
Do you give permission for Hackney Shed to take videos and photos for archives and reporting to funders
Do you give permission for Hackney Shed to use videos and photos of you for marketing – this may include print, our website or social media

Health and medication *

	Yes or no
Do you consent to First Aid being carried out on you in an accident/incident?
Do you consent to being taken to hospital in an emergency?

Information and contact permissions *

	Yes or no
Do you give Hackney Shed permission to contact you to update you with information about Hackney Shed. For example- details about workshops, additional activities, news about the organisation.
Do you give permission for Hackney Shed to contact you about fundraising support for Hackney Shed.
Do you give permission for Hackney Shed to forward you relevant information from other companies. For example, free tickets to show, workshops, casting opportunities. (We will not give your details directly to other companies)

Signatures

Please sign below if you agree all the information on this form is correct.
Participants name *

First Name Last Name
Participants signature
Date *

Day Month Year
Please put a '-' between day/month/year. For example 23-10-2018 Date Picker Icon
Supporters information (if appropriate)
If you are under 18 YOU MUST also have the signature of a parent/ carer.

I confirm that the information on this form is correct. I consent to my child attending Hackney Shed. I agree with the travel arrangements for my child as stated on this form
Supporters name

First Name Last Name
Supporters signature
Date

Day Month Year
Please put a '-' between day/month/year. For example 23-10-2018 Date Picker Icon
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

Hackney Shed Collective Registration Form