Day Services Interest Form

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Applicant name:

Name of person completing this form, and relationship to prospective day service member:

Number of days per week you would like to attend

Privacy Statement

Your privacy is important to us. The information you tell us is private and stored on our student database. You can ask for a copy of the information we have about you at any time.

You can look at Key Documents to read the full statements. These policies tell you what we do with your information, how we store it, and how to ask for copies of your data.

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Section One: Your Personal Information

This information is about you, the student.

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What is your full name?

What is your date of birth?

What is your home address?

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Are you a Looked After Child, or in the care of your Local Authority?

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Section Two: Your Main Contact

This information is about the main person helping you get a place at Day Services. This could be your parent, carer, guardian or professional. We need this information so that we talk with them about your place at Day Services.

( indicates a required field)

What is their full name?

What is their relationship to you?

What is their home address?

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

What is their email address?

What is their phone number?

How would they like to be contacted?

By letter
By email
By phone

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Section Three: Your Health Conditions

This is information about you, the prospective Day Service member. We need to know about your health conditions and disabilities so that staff know how to help you during the day.

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What are your disabilities or health conditions?

(For example, do you have a learning disability? Are you autistic? Do you have ADHD?)

How do your health conditions affect your learning?

(For example, do you find it hard to learn new skills or to concentrate? Do you need resources in a certain way to learn?)

How do they affect your mobility?

(For example, do you find it hard to walk? Can you use stairs? Do you use a wheelchair or crutches?)

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Section Four: Goals and Interests

This is information about you, the prospective Day Service member. This information tells us what you want to work towards in future. This helps us support you to achieve your goals.

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What are your aspirations - what would you like to achieve in life?

(For example, do you want a specific job? Do you want to volunteer? Do you want to live alone or in supported living?)

Are there any sessions you are particularly interested in?

(For example, social history, arts & crafts, gardening & building maintenance, horticulture)

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Section Six: Extra Information

Is there any other information you would like us to know about you? Please tell us in the box below.

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What would you like Homefield to know about you?

How did you learn about Homefield College’s Day Service provision?

Privacy Statement

Section One: Your Personal Information

Section Two: Your Main Contact

Section Three: Your Health Conditions

Section Four: Goals and Interests

Section Six: Extra Information

Alternative Formats

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