ILEAP Member Subscription

There is an annual subscription of £12 per year to join the Charity, all subscriptions will be renewed on 1st September each year. Renewals are proratered depending on the month you join.

Please enter information on the form below to process your Member subscription.

If you are looking to renew a current membership please watch this tutorial for help

Email *

Password*

Retype Password *

Participants Details

First Name of Member *

Last Name *

Nickname (preferred name of participant) *

Date of Birth of Participant *

Please use the calendar button to choose your date of birth.

Address1 *

Address2

Town or village *

Post Code *

Home phone number

Mobile phone number

Emergency Contact Name *

If different from parent / carer

Emergency Phone Number *

Who has parental responsibility for the participant *

Is there anyone we should be aware of who should not pick up the participant?

if applicable

Yes

Please provide further details

Where do you go to school, college, work?

Languages Spoken *

Religion *

Ethnicity *

GP’s Name *

GP’s Address *

GP’s Phone Number *

Medical Number

Participants Individual Needs and their Mental Capacity

What is the diagnosis of the Participants disability? *

Participants Capacity to Make Decisions

ILEAP are not able to undertake capacity assessments for our members aged 16 years and over and have to assume that they have capacity to make decisions themselves.

If you believe that the participant named above, lacks capacity to make their own decisions in areas such as: sexual activity, safeguarding, decision making, finance, social media, independent travel, please can you inform us here and we will take this into consideration when thinking of their best interests, if any future scenarios arise where their safety is at risk.
As the majority of our members are still under the care of their parents /carers, in the first instance we will refer any safeguarding concerns to parents / carers / guardians as a matter of course, should you answer yes to this question. If you answer No, then we will assume that they have capacity and will leave them to make their own decisions (which may be poor decisions, such as unhealthy food choices, poor financial decisions such as ordering champagne instead of water, free to develop sexual relationships etc.)

The person named above lacks capacity in certain areas and I wish to be contacted if future scenarios arise where their safety is at risk *

Yes

Please give further details

* Does your loved one intend to travel to or from ILEAP sessions independently?

Yes

If Yes, please be aware that ILEAP Staff and Volunteers will only be responsible during the stated session times and may be unable to wait with your loved one due to other commitments on the day.

Participants Communication needs

Does the participant have trouble making themselves understood? *

Yes

Does the participant understand verbal communication?

Yes

If No, please tell us any techniques / resources that may help us to communicate

If Yes, please tell us any key words, signs, gestures that may help

Does the participant use sign language or any other non-verbal signs? *

Yes

If Yes, please tell us any useful signing information

Does the participant have any hearing loss? *

Yes

If Yes, please tell us any useful information (hearing)

Does the participant have any sight loss? *

Yes

If Yes, please tell us any useful information (sight)

Participants medication needs:

ILEAP are able to administer medication at our sessions, as long as we have all of the relevant information and you have given consent. The medication must be in date and in its original packaging. A 1:1 may need to be allocated for certain sessions.

Will the participant require medication at their chosen activity? *

Yes (Our 1:1 rates may apply)

If Yes, they may need an ILEAP 1:1 or provide their own DBS checked worker and any specialist equipment

MEDICATION 1

Name of Medication 1

Dosage of medication 1

Frequency of medication 1 (when to administer)

Consequence of non-administration?

MEDICATION 2

Name of Medication 2

Dosage of medication 2

Frequency of medication 2 (when to administer)

Consequence of non-administration?

MEDICATION 3

Name of Medication 3

Dosage of medication 3

Frequency of medication 3 (when to administer)

Consequence of non-administration?

MEDICATION 4

Name of Medication 4

Dosage of medication 4

Frequency of medication 4 (when to administer)

Consequence of non-administration? (4)

MEDICATION 5

Name of Medication 5

Dosage of medication 5

Frequency of medication 5 (when to administer)

Consequence of non-administration? (5)

MEDICATION 6

Name of Medication 6

Dosage of medication 6

Frequency of medication 6 (when to administer)

Consequence of non-administration? (6)

MEDICATION 7

Name of Medication 7

Dosage of medication 7

Frequency of medication 7 (when to administer)

Consequence of non-administration? (7)

MEDICATION 8

Name of Medication 8

Dosage of medication 8

Frequency of medication 8 (when to administer)

Consequence of non-administration? (8)

MEDICATION 9

Name of Medication 9

Dosage of medication 9

Frequency of medication 9 (when to administer)

Consequence of non-administration? (9)

MEDICATION 10

Name of Medication 10

Dosage of medication 10

Frequency of medication 10 (when to administer)

Consequence of non-administration? (10)

Does the participant have Epilepsy *

If yes we require a up to date copy of their personalised Epilepsy Care Plan. Please send us a copy either by email or by post.

Yes

If Yes we require an up to date copy of their personalised Epilepsy Care Plan. Please send us a copy preferably by email or by post.

Does the participant have any other medical needs? *

Yes

Please provide any further medical details

Does the participant have any allergies? *

Yes

Please provide further details (allergies)

Does the participant have diabetes? *

Yes

Please provide further details (diabetes)

Participants mobility needs

ILEAP are unable to provide moving and handling at our sessions so the Participant may need to bring their own additional support and / or specialist equipment if they need lifting.

Does the participant require lifting? *

If yes, they will need to provide their own DBS checked worker and any specialist equipment

Yes

If Yes, they will need to provide their own DBS checked worker and any specialist equipment.

Please provide further details (lifting)

Does the participant walk unaided? *

Yes

If No, the participant may need an ILEAP 1:1 or provide their own DBS checked worker and any specialist equipment

Please provide further details (walk unaided)

Does the participant use a wheelchair? *

Yes

If Yes, the participant may need an ILEAP 1:1 or provide their own DBS checked worker and any specialist equipment.

Please provide further details, for example will need a 1:1 to push / or uses a powered chair.

Does the participant use specialist equipment? e.g. hoist *

Yes

If Yes, the participant may need to provide their own DBS checked worker and any specialist equipment

Please provide further details (specialist equipment)

Can the participant manage steps and stairs? *

Yes

If No, the participant will need to check with us beforehand to make sure that the venue is suitable.

Please provide further details (stairs)

Participants Personal Care

ILEAP are able to provide Personal Care at our sessions. So that we can meet your needs effectively, please tell us:

Does the participant go to the toilet unprompted? *

Yes

If No, they may need an ILEAP 1:1 or provide their own DBS checked worker and any specialist equipment

Please provide further details (toilet)

Does the participant need reminding to go to the toilet? * *

Yes

If Yes, they may need an ILEAP 1:1 or provide their own DBS checked worker and any specialist equipment

Please provide further details (toilet remind)

Does the participant need to be supervised whilst in the toilet? * *

Yes

If Yes, they may need an ILEAP 1:1 or provide their own DBS checked worker and any specialist equipment

Please provide further details (toilet supervision)

Does the participant Wear nappies or pads or require other personal equipment ? *

Yes

If Yes, they may need an ILEAP 1:1 or provide their own DBS checked worker and any specialist equipment

Please provide further details (nappies/pads)

Does the participant use special words or signs to indicate they need the toilet? *

Yes

Participants Safety

Please tell us is the participant

Please provide further details (toilet words)

Aware of dangers *

Yes

Please provide further details (dangers) *

Likely to run away / hide from the group etc.? *

Yes

A 1:1 may be required, please provide further details

We run our group sessions on a ratio of 1 DBS checked member of ILEAP staff / volunteer, looking after 4 or 5 participants (1:4, 1:5)

Is this appropriate? *

Yes

Participants Behavioural needs

ILEAP are unable to use physical restraint at our sessions. You may need to bring your own additional support if you are likely to put yourself or others at risk.
Please tell us, does the participant

Have any behaviour that might affect others e.g. biting / scratching *

Yes

Please describe this behaviour (biting/scratching)

What might trigger the above behaviour?

What is the best way to deal with the behaviour?

What is the best way of comforting / reassuring them?

Participants Dietary needs

Does the participant need any help with eating or drinking? *

Yes

Please provide further details (feeding)

Have any specific routines i.e warming, mashing food? *

Yes

Please provide further details (feeding routine)

Does the participant have a special diet? *

Yes

Please provide further details (special diet)

Does the participant have any allergies or food you do not want them to eat? *

Yes

Please provide further details (food allergies)

Participants Play / Leisure needs

Does the participant have any favourite activities? *

Yes

Please provide further details

Does the participant have a least favourite activities? *

Yes

Please provide further details

Does the participant want to try a particular activity? e.g. Archery etc. *

Yes

Please provide further details

Does the participant want to visit a particular attraction? e.g. Alton Towers *

Yes

Please provide further details

Participants Personality

Please provide a brief pen portrait about the Participants personality, e.g. (happy/affectionate / great sense of humour)

Personality Details

Additional Information

Please use this space to provide any further information that will be of use to the ILEAP Staff and your chosen leisure provider, so that they can ensure your safety and enjoyment.

Additional Information

We will review this information and if necessary, may send you a medication form to complete.

How did you hear about ILEAP and our services?

Payment Information

Coupon

Price for membership until 31 August

Discount Amount

Total Amount

Payment Method *

Credit or Debit Card

PayPal

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Holder Name*

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