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Special Hands Activity Group

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Membership Application

Proposed Members name*

Address*

Date of Birth*

Day

Month

Year

Guardian 1*

Email*

Phone*

Address*

Relationship to member*

Guardian 2*

Email*

Phone*

Address*

Relationship to member*

Permission to contact Guardian 1*

Yes

No

Permission to contact Guardian 2*

Yes

No

Permission to add you to our Facebook Page*

Guardian 1

Guardian 2

Diagnosis if known*

Does the member have any of the following*

Asthma

Epilepsy

Heart Conditions

Low Blood Pressure

Poor Vision

Loss of hearing

Mobility Issues

Behavioral Issues

Please Provide any additional information that may be relevant to the members ability to participate fully in activities.*

By Checking this box you argree to allow Special Hands Activity Group to include the member in photographs of the group activities and events. Photographs may be used for fundraising, publicity, press and social media.

By signing this membership I agree to abide by the code of conduct when participating in or attending events organised and administered by Special Hands Activity Group.

Signature*

Date*

Day

Month

Year

Special Hands Activity Group is a registered Charity

CHY 15635

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