PEERS MemberSHIP FORM


To download a printable copy of this form click here, and send by mail to the address listed on the top of the form.

REQUIRED INFORMATION
DATE OF APPLICATION
DATE OF APPLICATION
NAME
NAME
ADDRESS
ADDRESS
PHONE NUMBER
PHONE NUMBER
MOBILE NUMBER
MOBILE NUMBER
DATE OF BIRTH
DATE OF BIRTH
PRIMARY EMERGENCY CONTACT PERSON
NAME
NAME
MOBILE PHONE NUMBER
MOBILE PHONE NUMBER
WORK PHONE NUMBER
WORK PHONE NUMBER
SECONDARY EMERGENCY CONTACT PERSON
NAME
NAME
MOBILE PHONE NUMBER
MOBILE PHONE NUMBER
WORK PHONE NUMBER
WORK PHONE NUMBER
PERMISSIONS
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)
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.
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.)
NAME OF WITNESS
NAME OF WITNESS
THIS ADDITIONAL INFORMATION IS OPTIONAL, BUT WOULD BE EXTREMELY HELPFUL TO US AT PHAB
DO YOU NEED MOBILITY ASSISTANCE?
If you answered "YES" to needing mobility assistance, please choose from the following options . . .
If you answered "YES" to needing mobility assistance, can you transfer?
DO YOU REQUIRE ASSISTANCE WITH TOILETING?
DO YOU REQUIRE ASSISTANCE WITH FEEDING?
ARE YOU VISUALLY IMPAIRED?
ARE YOU HEARING IMPAIRED?
DO YOU TAKE ANY MEDICATIONS?
DO YOU HAVE ANY ALLERGIES?
DO YOU HAVE A TOTAL MOBILITY CARD?