ARE YOU A DDPTV MEMBER?
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You confirm that (please tick):
HOW LONG HAVE YOU BEEN A DDPTV MEMBER?
Please select from the below:
I am not a member
1-6 months
6-12 months
1-2 years
2-3 years
3-4 years
4-5 years
5-6 years
6-7 years
7-8 years
8-9 years
10+ years
I am NOT
By completing and submitting this ACCESS FORM you consent to us processing any special category personal data that you have provided in this form in accordance with our privacy policy www.ddptv.org/privacy-policy If you don’t not consent, please do not complete this form. You have a right to withdraw this consent at any time by contacting info@ddptv.org
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You confirm that (please tick):
POSTCODE
PRONOUNS:
NAME:
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First Name
Last Name
CONTACT NUMBER:
DO YOU REQUIRE TEXT MESSAGE ONLY?
b. THE PHYSICAL SPACES AND ENVIRONMENTS YOU GO INTO
Examples of adjustments for physical spaces and environments might include:
• step-free access
• limiting the distances you need to walk
• regular opportunities to sit down
• a ‘quiet zone’ to relax in
• limiting any anxiety triggers
• reducing background noise
• seeing plans or pictures of the space before going there
c. HOW YOU COMMUNICATE AND LIKE TO BUILD RELATIONSHIPS
Examples of adjustments around communication and making relationships might include:
• a Sign Language Interpreter - please state whether British Sign Language (BSL), Irish Sign Language (ISL), or Sign Supported English (SSE).
• do you have a preferred Sign Language Interpreter or lip speaker you would like to work with? If so, please give details, with their consent.
• your preferred font to read from
• the time you need to process your thoughts before answering questions
• clear, simple and repeated explanations of what’s happening
• written instructions, instead of spoken ones
• getting information in advance of a meeting or event
• Easy Read versions of documents
• pictures and profiles of key team members
• meeting key people before starting
• people wearing name badges
d. YOUR WORKING DAY – INCLUDING TRANSPORT, WORKING HOURS AND ROUTINE
Examples of adjustments related to your working day might include:
• using taxis instead of public transport / specific kinds of taxis
• needing an accessible, dedicated parking space
• how long you can work or be in meetings for at any one time
• how often you need breaks and for how long
• a ‘no earlier than’ start time or ‘no later than’ finish time
• scheduled toilet breaks / immediate access to an accessible toilet
• how often you need to eat & drink / where you prefer to have your lunch
• any foods or drinks you avoid
• the need to take medication or receive treatment
e. THE SUPPORT YOU NEED FROM OTHERS
Examples of adjustments for the support you need from others might include:
• a BSL interpreter - please state whether British Sign Language (BSL), Irish Sign Language (ISL), or Sign Supported English (SSE).
• equipment you need supplied or will bring with you
• a support worker
• a preferred chaperone
• an assistance animal
h. ALLERGIES
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As this is an in-person event, we would like to know if you have have any allergies? This could be one or a mixture of foods, animals, pollen, mold, dust mites, medications, insect stings , perfumes and/or household chemicals.
i. DIETARY REQUIREMENTS
Do you have any dietary requirements? If so, please outline below.
PERMISSIONS
Has your support worker given their permission for you to supply their information?
PRIMARY SUPPORT WORKER'S NAME
PRIMARY SUPPORT WORKER'S EMAIL
SHALL WE COPY IN YOUR PRIMARY SUPPORT WORKER ON ALL EMAILS TO YOU?
PRIMARY SUPPORT WORKERS TELEPHONE NUMBER
DOES YOUR PRIMARY SUPPORT WORKER REQUIRE TEXT MESSAGE ONLY?
IF YOU REQUIRE MORE THAN ONE SUPPORT WORKER PLEASE ELABORATE BELOW
If you have permission to supply names and contract information, please do so.
PERMISSIONS
Has your next of kin given their permission for you to supply their information?
NEXT OF KIN’S NAME:
NEXT OF KIN'S RELATIONSHIP TO YOU
NEXT OF KIN'S EMAIL
NEXT OF KIN'S TELEPHONE NUMBER
DOES YOUR NEXT OF KIN REQUIRE TEXT MESSAGE ONLY?
IS THERE ANYTHING ELSE YOU WOULD LIKE TO SHARE?
