Adult Referral Form

EMERGENCY CONTACT DETAILS

TRANSFERS

MOBILITY AIDS REQUIRED

PLEASE TICK ALL THAT APPLY SENSORY PROBLEMS

Frequency Potential

Who may be affected by the behaviour

Potential Triggers

Potential Hazards

List below the hazards identified and the controls to be put in place for the Service User:

Consent

1. Activities may be recorded through photographs and video film both for the participant to celebrate their experiences but also for evaluation and promotional purposes by the Royal Borough of Greenwich.   I agree that the images may be used in media or publicity materials and celebration publications produced by the Royal Borough of Greenwich.  I understand that these images may be safely stored or archived digitally or manually and may be publicised in a variety of media forms including managed social network sites.

(Please tick one):

• provide consent for such image(s) to be used at any time for promotional or publicity purposes
• DO NOT provide consent for such image(s) to be used at any time for promotional or publicity purposes
  
  

1. The Royal Borough of Greenwich may use your contact details to contact you to discuss your experience of the programme:

• consent to be contacted regarding my experience of the programme
• DO NOT provide consent to be contacted regarding my experiences of the programme
  
  

1. The Royal Borough of Greenwich may use your contact details to contact you regarding future Holiday Activity Programmes that may be of interest:

• provide consent to be contacted in future regarding future Holiday Activity Programmes

DO NOT provide consent to be contacted in future regarding future Holiday Activity Programmes