DATE OF APPLICATION

MM

DD

YYYY

NAME

First Name

Last Name

ADDRESS

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

PHONE NUMBER

(###)

###

####

MOBILE NUMBER

(###)

###

####

DATE OF BIRTH

MM

DD

YYYY

NAME

First Name

Last Name

MOBILE PHONE NUMBER

(###)

###

####

WORK PHONE NUMBER

(###)

###

####

NAME

First Name

Last Name

MOBILE PHONE NUMBER

(###)

###

####

WORK PHONE NUMBER

(###)

###

####

I give permission for my photograph to be taken, and understand that PHAB reserves the right to use the images in advertising, marketing and promotional materials. (This includes the PHAB Website, Social Networking Sites and Brochures)

YES

NO

I give permission for the above information to be kept on file, and to be given to medical authorities in the event of illness or accident.

YES

NO

I understand that, should medical treatment be necessary, every effort will be made to obtain my consent. However in an emergency, I authorise the youth worker to consent on my behalf to any medical treatment which a qualified doctor feels is necessary. (This could include inoculations, blood transfusions, surgery or the use of anaesthetics.)

YES

NO

NAME OF WITNESS

First Name

Last Name

DO YOU NEED MOBILITY ASSISTANCE?

YES

NO

If you answered "YES" to needing mobility assistance, please choose from the following options . . .

Manual Wheelchair

Power Chair

Scooter

Walking Frame

If you answered "YES" to needing mobility assistance, can you transfer?

YES

NO

DO YOU REQUIRE ASSISTANCE WITH TOILETING?

YES

NO

DO YOU REQUIRE ASSISTANCE WITH FEEDING?

YES

NO

ARE YOU VISUALLY IMPAIRED?

YES

NO

ARE YOU HEARING IMPAIRED?

YES

NO

DO YOU TAKE ANY MEDICATIONS?

YES

NO

DO YOU HAVE ANY ALLERGIES?

YES

NO

DO YOU HAVE A TOTAL MOBILITY CARD?

YES

NO