Young People’s Service Essential Information

Young Person’s Personal Information

Forename:	Surname:

Preferred Name:

Date of Birth:	/	/	Gender:	Male / Female

Ethnic Origin:	Religion:

Address:	_____

______________________________________________________________________

_____	______Post Code_________________

Phone Number(s) (incl STD):

Mobile Numbers _____________________________________________________________

GP:

Name	Address	Telephone Number

Emergency Contact Information:

Name	Relationship	Home Telephone	Work Telephone	Mobile Telephone

What is the nature of the young person’s disability?

How does the above affect the young person’s every day functioning?

How does the young person communicate with others?

What level of support does the young person need (e.g. one or two members of staff)?

Does the young person use any special equipment (e.g. Wheelchair)?

What is the young person’s level / dependency for toileting (e.g. use of any

equipment / aids, pads, normal routine etc)?

What significant risks affect the young person?

If the young person becomes distressed or aggressive, how is the situation best dealt with?

Medical Information

Does the young person have any ongoing health concerns? Please give details:

Is the young person taking regular medication? Please fill in details of medication below:

Name of Medication	Strength/ Suspension	Dosage	Directions
Eg. Paracetamol	500mg	2 tablets	With water, after food

Is this medication likely to need administering during a youth club/project hours? Please delete as applicable: Yes / No

If yes, please give details:

Time	Medication	Dosage

Is the young person epileptic? Yes / No

If yes please let us know what course of action to take if required?

Please give details of any further medical needs below e.g. Gastro feeds

Does the young person have any allergies? Please fill in details below:

Substance	Nature of Substance	Symptoms
eg. Penicillin	Antibiotic	Anaphylactic shock

Can the young person’s GP be contacted if necessary? Yes / No

Does the young person have any specific dietary requirements? Please give details:

Is the young person able to travel by: (delete as applicable)

Car	Yes / No

Minibus	Yes / No

With special adaptations / without special adaptations

Name of person completing record: ________________________

Relationship to young person: _____________________________

Signature _______________________________________	Date ___ / ___ / ___

Office Use	Date Received:	Officer:	Date of Destruction: