Update of Details

DATABASE INFORMATION SHEET FOR INDIVIDUAL SERVICE USERS

The details submitted will only be used to keep service users up to date with current and new sporting provision provided by Glasgow Life/Glasgow Sport Please complete all information as fully as possible.

Participants Name:......

Date of Birth:-...... Age:-………………

Emergency Contact......

Emergency Contact Number:......

Email:-......

Address:-......

...... Post Code:-......

Session/s you attend:-……………………………………………………………………

Nature of Disability eg: Learning/Physical/Sensory, Please state:-......

......

Medical Information - Does your child have any additional medical condition including Asthma, Heart Condition or Diabetes, which may require medical treatment including medication? YES NO

If yes, please give details

......

Does your child have any allergies, including those to medications? YES NO

If yes, please give details

......

Does your child have epilepsy? YES NO If Yes, please complete questions below. What type of epilepsy do you have?………………………………………………

Major Seizures (convulsive) YES NO Minor Seizures YES NO

Other (please specify) ………………………………………………………………………………………

………………………………………………………………………………………. How often do these seizures occur? …………………………………………………

Are you on any medication? YES NO

If ‘yes’ have you included details on the application form?

YES NO

Do you know when you are going to have a seizure? YES NO

If ‘yes’, what signs and symptoms should the coach look for?

………………………………………………………………………………………..

Could you please describe your typical seizures?

…………………………………………………………………………………………

………………………………………………………………………………………

How long do they usually last? ………………………………………………………

Do we need to know of any emergency procedures? YES NO

Please give details of any emergency procedures and after how long they should be put into operation.

………………………………………………………………………………………… ……………………………………………………………………………………… DECLARATION

Information on child’s disability/support needs, behaviour and medication Please give any relevant information on your child’s disability/support needs and/or behaviour (including where appropriate, medication). This information will be used to help us determine the appropriate levels of support for your child. Please include any other information you wish to regarding your child particularly in relation to his/her mobility, which might assist the coaches to deliver an appropriate programme.

………………………………………………………………………………………………

…………………………………………………………………………………………......

Please provide any other relevant information about the participant which you as the parent/guardian would like to make Glasgow Sport aware of, e.g. phobias, dislikes etc.

………………………………………………………………………………………………..

To the best of my ability I consider my child to be in good health and capable of taking part in these activities YES NO

I agree to notify Glasgow Sport staff of any changes to the information given on this parent/guardian consent form for the duration of the sessions. YES NO

Signed: ………………………………………………… Date: ………………..…… To help us monitor and analyse diversity information please complete and return with update form.

1. Decline to complete: I prefer not to complete this form

2. Gender: Male Female

3. What is your ethnicity? Ethnic group categories are not about nationality, place of birth or citizenship. They are about the group to which you as an individual perceive you belong. Please indicate your ethnic group by ticking the appropriate box.

White English Welsh Scottish Northern Irish Irish Gypsy or Irish Traveller Other White background

Mixed/multiple ethnic groups White and Black Caribbean White and Black African White and Asian Any other mixed background

Asian/Asian British Indian Pakistani Bangladeshi Chinese Any other Asian background

Black/African/Caribbean/Black British African Caribbean Any other Black/African/Caribbean background

Other ethnic group Arab Any other ethnic group

8. What is your religion or belief?

No religion Buddhist Christian Hindu Jewish Muslim Sikh Any other religion

Thank you for completing this form.