SOCIAL SHINDIGS APPLICATION FORM SERVICE USER INFORMATION LIVING ARRANGEMENT
If in group home, name of case manager / key worker:
1ST EMERGENCY CONTACT 2ND EMERGENCY CONTACT PERSONAL DOCTOR OR MEDICAL CENTRE DETAILS
Surgery/Medical Centre’s Name: Phone:
PLEASE COMPLETE ALL OF THE FOLLOWING QUESTIONS
Do you have any medical history that we should be aware of? (e.g. asthma, diabetes, heart condition). If so, please list.
Questions continue over the page SOCIAL SHINDIGS APPLICATION FORM
If you have epilepsy, what epilepsy management plan would you like us to follow? (e.g. call emergency
contact immediately, call ambulance if seizure longer than 5 minutes) Do you take any medication? (e.g. ventolin, insulin). If so, please list. Do you have any al ergies? (e.g. foods, medication, bee stings, latex). If so, please list. Do you have any special dietary needs? (e.g. vegetarian, lactose intolerance, gluten free). If so, please list. Do you have any particular dislikes or fears? (e.g. loud music, crowds, lifts, dogs).
Do you have any other special needs we need to know about? (i.e Behaviour plans, social anxieties).
What is the nature and degree (mild, moderate, severe) of your disability? What level of support do you require when involved in community activities? (e.g. in relation to self care, mobility, communication, behaviour) Are you able to socialize in the community without the help of carers? (Please circle)
Questions continue over the page SOCIAL SHINDIGS APPLICATION FORM PRIVACY STATEMENT Social Shindig Services (SSS) are committed to the protection of personal privacy as required under the
Privacy and Personal Information Protection Act 1998 (NSW). SSS will not collect or monitor any personal
information about you without your consent unless it is required by law, and will endeavor to take al reasonable steps to keep secure any information which we hold about you. Your personal information is
collected and used solely for and ancillary to the administration and purposes of SSS and its events. All personal information relating to service users are confidential and are only made available to authorized
staff or medical personnel in the case of an emergency. If at any time you want to know exactly what personal information SSS is holding about you, you are welcome to request such information by emailing
Please note that it is your responsibility to update personal information that is inaccurate or out of date and this can be done by emailin I consent to the collection, use and disclosure of my personal information but strictly as stated above.
SOCIAL SHINDIG SERVICES RELEASE & IDMENITY AGREEMENT I hereby waive, release and forever discharge Social Shindig Services (SSS), its staff and volunteers from,
and indemnify SSS from all claims that I may have had but for this release arising from or in connection with my participation in SSS activities, and I also hereby indemnify and undertake to keep any other
person arising as a result of or in connection with my participation in SSS activities and, without limiting the generality of the foregoing, from and against any and all costs, damages, expenses, claims, demands, actions and liabilities arising from any accident, loss or injury suffered or incurred by me or any others in
connection with any attendance, involvement or participation on my part at any activity of SSS. Should at any time the supervisors consider that I require medical, hospital or other health care treatment or
emergency (including ambulance) transportation, I consent to SSS obtaining the same directly at my expense. In that regard, I undertake to pay al medical or ambulance costs associated with medical, hospital or other health care treatment which I may require as assessed by the treatment providers. I am
also aware that any personal equipment that is lost, damaged or stolen will not be replaced or reimbursed by Social Shindig Services.
Please return your completed & signed form:
By Mail to: Social Shindig Services, 18 McEvoy Avenue Umina Beach NSW 2257
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