Woodlands Club Registration FormPlease enable JavaScript in your browser to complete this form. - Step 1 of 6NameGender: MaleFemaleDate of BirthAddressAddress Line 1CityState / Province / RegionPostal CodeOther CommentsNextNEXT OF KIN /EMERGENCY CONTACT DETAILSName of Next of KinAddress Address Line 1CityState / Province / RegionPostal CodePhoneMobile NumberEmailRelationship2nd Emergency Contact2nd Name of Next of KinPhoneMobile NumberEmailGENERAL PRACTITIONER DETAILSGP's Address Address Line 1CityState / Province / RegionPostal CodeNHS NumberHave you received the COVID 19 vaccine?Vaccine 1Vaccine 2Booster 1Booster 2(please tick appropriate box)Please provide details of vaccine statusSpecial Dietary RequirementsAllergiesDo you require assistance with:EatingToiletMobilityTransportPlease provide explanation of needsPreviousNextINVOICING & PAYMENT DETAILSSelf FundingSocial Services(please tick appropriate box)NameFirstLastAddress Line 1CityState / Province / RegionPostal CodeDays missed will not be refunded for any reasons other than *hospitalisation and Covid.Please tick to confirm you have read and agreedPreviousNextDays AttendingStart DatePlease select Days attendingMondayTuesdayWednesdayThursdayFridayRate Per Day is £80Should you wish to no longer attend the Woodlands Club, one week's notice will need to be given. Accounting will be up to the period of notice.Please tick to confirm you have read and agreedPreviousNextMedical QuestionnairePlease Select Yes or NoDo we have your permission to resuscitate the client? YesNoDo we have your permission to administer your EpiPen in the event of Anaphylactic reaction? YesNoNot Applicable(Please Supply EpiPen)Do we have your permission to administer Aspirin to the client in the event of a heart attack?YesNoDo we have your permission to administer Paracetamol to the client in the event of a headache or anything requiring pain control?YesNoDo we have your permission to administer GTN spray to the client when required if they have been diagnosed with angina or a heart condition? YesNoNot Applicable(Please Supply GTN spray)Are you currently on blood thinners? YesNoPlease supply an up to date current list of medication, this will help us in the unlikely event of the emergency services being called to the centre. It is the responsibility of the family to inform and update Woodlands Club of any changes with regard to medication.Any other comments/NotesPlease tick to confirm you have read and agreedPreviousNextMedical ConditionsPlease tick next to any medical condition listed below which you have been diagnosed with. Please also note year (if known) of diagnosis. The list is extensive to help ensure that we have a complete history, please do not be concerned if you do not recognise all of the terms:Hypertension (High blood pressure)YesNoDiabetesYesNoHigh CholesterolYesNoHeart and Related DisordersAnginaYesNoAny other heart conditionYesNoNeurologic DisordersStrokeYesNoIf yes, please provide further detailsDementiaYesNoIf yes, please provide further details Parkinson's DiseaseYesNoIf yes, please provide further details MiscellaneousIncontinenceYesNoIf yes, please provide further detailsPreviousSubmit
