SOCIAL CLUB MEMBERSHIP FORM (APPLICANT) - Auckland Down Syndrome Association (ADSA)

YOUR DETAILS

Name *

First

Last

Gender *

Male
Female

Date of Birth *

Are you attending: *

School
University
Work
Other

If 'Other', please specify your daily care, eg. stay at home, attend care *

Ethnicity *

Hapu/Iwi

CAREGIVER & EMERGENCY CONTACT DETAILS

Name of Parent/Guardian *

First

Last

What is their relationship to you? *

Home Address *

Suburb *

City *

Post Code *

Contact phone number *

Other contact phone number

Email *

Emergency Contact Name *

First

Last

Emergency contact phone number *

OTHER FAMILY INFORMATION

How many siblings do you have? *

Details of first sibling *

First

Last

Age of first sibling *

Details of second sibling *

First

Last

Age of second sibling *

Details of third *

First

Last

Age of third *

MOBILITY & FITNESS

Mobility and Fitness of Attendee *

	Poor	Average	Good	Excellent
How would you describe your swimming ability?	PoorHow would you describe your swimming ability? Poor	AverageHow would you describe your swimming ability? Average	GoodHow would you describe your swimming ability? Good	ExcellentHow would you describe your swimming ability? Excellent
How would you describe your fitness?	PoorHow would you describe your fitness? Poor	AverageHow would you describe your fitness? Average	GoodHow would you describe your fitness? Good	ExcellentHow would you describe your fitness? Excellent

COMMUNICATION

Do you have a hearing impairment? *

If yes, please specify what hearing aids are used *

Do you have a vision impairment? *

If yes, please specify what vision aids you use *

Do you have difficulty with speech? *

If yes, please specify what communication aids you use *

Do you have difficulty understanding and listening to instructions? *

MEDICATION

Do you have any medical allergies, eg. bee stings, penicillin etc *

If yes, please specify what allergies and medication you require *

Have you experienced seizures *

If yes, are seizures likely to happen again, and how can we manage this if so? *

Are you currently on any medications? *

If yes, please specify all medications *

If you have any other medical conditions we should be aware of, please specify *

DIET

Do you eat and drink unaided? *

Do you have special dietary requirements? *

If yes, what are they *

Do you have any food allergies/reactions? eg. are there any foods or liquids you cannot eat or drink? *

It is very important that we have a clear understanding of your eating habits:

LIKES *

DISLIKES *

DRESSING & SHOWERING

Can you dress unaided? *

If No, please specify area for assistance (eg. buttons, shoelaces etc) *

Can you shower unaided? *

If No, please specify area for assistance (eg. buttons, shoelaces etc) *

Can you regulate hot water temperature? *

If No, please specify area for assistance *

TOILETING

Can you toilet unaided? *

If No, please provide further information *

Do you require strict toilet reminding during the day or before bedtime? *

If Yes, please provide further information *

SOCIALISATION & BEHAVIOUR

Do you find it difficult to get to know new people? *

If Yes, please provide further information *

When in new environments, what helps you to feel safe and comfortable? *

Do you have any behavioural difficulties that we need to be aware of? *

If Yes, please provide further information *

How do you respond to difficult or challenging situations? *

GENERAL

Do you consent to photographs being taken for possible publicity use? *

Do you consent to this information being filed for future reference? *

DISCLAIMER

This information is collected on behalf of Recreate NZ by the Auckland Down Syndrome Association for the purposes of their social club. In the event of an accident or illness, I authorise the obtaining of any medical assistance on my behalf as may be deemed necessary by the staff of Recreate NZ. I AGREE THAT Recreate NZ supervising staff, any other organisations involved, and helpers/volunteers will not be legally liable for any accident, injury or occurrence to myself during this programme. While recognising that Recreate staff will be doing their best to ensure the care, safety and management of the risks inherent in the activities I am participating in, I accept responsibility for my own actions and safety. I AGREE THAT if my behaviour during the course of the programme threatens the wellbeing of staff and other participants, Recreate NZ has the right to send me home and I will be liable for any costs incurred. I AGREE TO cover the full payment of programmes, including timely payment of membership fees. I understand that Recreate NZ will not accept responsibility for loss or damage to personal property. I AGREE TO the above information being added to the ADSA and Recreate NZ’s database so I can be informed of future social club events. I AGREE TO the above information being kept on file for future reference in regards to ADSA social clubs.

I have read the above statement and agree to the conditions specified. *

My parent or caregiver has read the above statement and agrees to the conditions specified. *

Please make sure you press the SUBMIT button. You will receive a copy of the form you submitted; please check your junk/spam folder.

If you would like to join either the youth or adult ADSA Social Club, please fill out the form below.

YOUR DETAILS

CAREGIVER & EMERGENCY CONTACT DETAILS

OTHER FAMILY INFORMATION

MOBILITY & FITNESS

COMMUNICATION

MEDICATION

DIET

DRESSING & SHOWERING

TOILETING

SOCIALISATION & BEHAVIOUR

GENERAL

DISCLAIMER