Fillable A-place-to-grow-registration-form A Place To Grow Registration Form

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A-place-to-grow-registration-form A Place To Grow Registration Form

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REGISTRATION FORM
A Place To Grow is a Community Garden that promotes
positive health and wellbeing for Blaby District residents
SECTION 1 – PERSONAL DETAILS
Name:…………………………………………………………………………………………………………………………………….
Address:…………………………………………………………………………………………………………………………………
…………………………………………………………………………Post Code:……………………………………………………
Date of Birth: ………………………………………………………………………………………………………………………..
Home Telephone No:………………………………………..Mobile No:………………………………………………….
Email Address:………………………………………………………………………………………………………………………..
EMERGENCY CONTACT DETAILS:
Contact Name:……………………………………………………….Tel No: …………………………………………………
Relationship:………………………………………………………Mobile No:……………………………………………….
GP DETAILS:
Address:…………………………………………………………………………………………………………………………………
……………………………………………………………………………… Tel No:…………………………………………………
ANY OTHER HEALTH PROFESSIONAL YOU ARE WORKING WITH:
Name:…………………………………………………………………………………………………………………………………….
Address:………………………………………………………………………………………………………………………………..
Tel No:…………………………………………………………………………………………………………………………………..
Email:……………………………………………………………………………………………………………………………………..
PAST GARDENING EXPERIENCE (Details of any previous experience):
EXPECTATIONS: (Please list what you hope to gain from attending the project, i.e. meet
people / improve confidence / learn new skills):
TRAVEL ARRANGEMENTS (How do you plan to travel to the site)?
SPECIALIST SUPPORT (Please give details of any specialist support that may be necessary to
ensure that A Place to Grow Project is a positive experience for you)?
DATA PROTECTION
The personal information you supply to Blaby District Council in this form will be
processed in accordance with the General Data Protection Regulation (GDPR) and the
Data Protection Act 2018 (when in force). We may share this information with other
council departments, local authorities, government departments or law enforcement
organisations to improve service delivery or for the prevention or detection of crime and
fraud where the law allows this. Further information on how we handle your personal
information can be found on the Data Protection Notice web page.
Please tick the box to say you have read and understood the above statement
SECTION 2 - HEALTH FORM
This information required below enables A Place to Grow to provide a suitable, safe and
enjoyable working environment.
Please answer the following questions and provide details if answering ‘Yes’
Do you have a cardiac condition?
No □ Yes □ ………………………………………………………………………………………………………..
Do you have a respiratory condition?
No □ Yes □ ………………………………………………………………………………………………………..
Do you suffer with epilepsy?
No □ Yes □ ………………………………………………………………………………………………………..
Do you suffer with diabetes?
No □ Yes □ ………………………………………………………………………………………………………..
Do you suffer with allergies?
No □ Yes □ ………………………………………………………………………………………………………..
Do you have any mental health needs?
No □ Yes □ ………………………………………………………………………………………………………..
Please answer the following questions and provide details if answering ‘Yes’
Do you have hearing impairment?
No □ Yes □
details of any preferred method of communication (lip reading, BSL or written, etc.)
…………………………………………………………………………………………………………………………………………
Do you have visual impairment?
No □ Yes □ ………………………………………………………………………………………………………..
Do you experience any phobias?
No □ Yes □ ………………………………………………………………………………………………………..
Do you experience medication side effects that may affect your work in the garden?
(e.g. drowsiness, sensitivity to sunlight)
No □ Yes □ ………………………………………………………………………………………………………..
I understand that I retain full responsibility for my health and safety while attending the A
Place To Grow site (please to tick the box to confirm you understand this)
SECTION 3 - EQUAL OPPORTUNITIES MONITORING FORM
A Place to Grow is committed to the principle of equal opportunities for all. Please answer
the following questions:
AGE
16-25 □ 25-34 □ 35-44 □ 45-54□ 55-64 □ 65+ □
GENDER
Female □ Male □
ETHNIC GROUP
Please indicate your ethnic group:
WHITE
MIXED
ASIAN OR
ASIAN
BRITISH
GYPSY/TRAVELLER
British □
White and
Black
Caribbean□
Indian □
Gypsy/traveller
□
Irish □
White and
Black African
□
Pakistani
□
Other
white
□
White and
Asian □
Bangladeshi
□
Mixed
British □
Other Asian
□
Other Mixed
□
DISABILITY
The Disability Discrimination Act 1995 (DDA) protects people with a disability. The DDA
defines a person as having a disability if they have a physical or mental impairment, which
has a substantial, long term (i.e. has lasted or is expected to last at least 12 months) and has
an adverse effect on the person’s ability to carry out normal day-to-day activities.
Do you consider yourself to have a disability according to the description given above?
No □ Yes □
Are you registered as having a disability?
No □ Yes □
SECTION 4 - SIGNATURE
The information I have provided is given to the best of my knowledge. I will inform Blaby
District Council of any change in circumstances.
Signature:……………………………………………………………Date:…………………………………………………………
Print name below if signing on behalf of the applicant and provide a contact phone number:
Name:……………………………………………………………………………Phone No: ……………………………………..
Relationship to applicant:………………………………………………………………………………………………………
Please return this form to the Health & Leisure Services Team
at Blaby District Council
Post: Blaby District Council, Council Offices, Desford Road, Narborough,
Leicestershire, LE19 2EP
Email: leisure@blaby.gov.uk
Any questions?
Please call us on 0116 272 7703
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A-place-to-grow-registration-form A Place To Grow Registration Form

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Completed 9 July 2020

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