Register with Best Life Day Club

Contact details

First name

Please enter your first name.

Last name

Please enter your last name.

Please enter a valid email address.

Mobile

Phone

Additional notes

Show address fields

Address

City

County or region

Postcode

Country

Children

Child's first name

Child's last name

DOB

Medical notes

Does the client have dementia or memory problems? *

If they have dementia, do you know what type? *

Does the client have any allergies? *

Do they have any communication challenges? *

Do they have any mobility needs? *

Have they had their Covid-19 vaccinations? *

Client address *

Please specify the home address of the client here.

Day club *

Free taster session date *

Please let us know what date you would like to book your free taster session for

Photo/video permission *

We will email you weekly summaries including photos and videos of your loved ones time at the club, and occasionally post some pictures on social media, to invite new people to join. If you do not wish for this to happen then please select ‘no’ (you will still receive the weekly summary in writing with photos but we will not take any photos or videos of your loved one)

Emergency contact 1 - Name *

Emergency contact 1 - Number *

Emergency contact 1 - Relationship to client *

Emergency contact 2 - Name *

Emergency contact 2 - Number *

Emergency contact 2 - Relationship to client *

Email address for billing *

If different from client email, otherwise leave blank.

How will the client travel to and from the club? *

Please specify all that apply (private car, taxi, community bus etc).

Are they able to feed themselves? *

Are they able to toilet themselves? *

Does the client ever get anxious? *

Emotional Triggers *

Does the client have any emotional triggers that we need to know about?

Any tips for if client becomes unsettled? *

Client's first language? *

If more than one language spoken, please list

Client's religion? *

What did the client used to do for work? *

Do they have any family? *

Relationship to representative *

Hobbies and interests *

What do they enjoy doing? Have they previously enjoyed any hobbies or interests?

Dietary requirements/food allergies *

Does the client have any dietary requirements/food allergies?

Recent events *

Has the client recently experienced any life changing events?

Life Story *

Can you tell us anything else about their life history?

How did you hear about us? *

Deprivation of Liberty Safeguards *

Does the client have any Deprivation of Liberty Safeguards?

Mental Capacity *

Has the client had a mental health capacity assessment?

Power of Attorney - finance *

Name of P of A - finance:

Power Of Attorney - Health and Welfare *

Name of P of A - Health and Welfare:

Add a child

Child's first name

Child's last name

DOB

Medical notes

Does the client have dementia or memory problems? *

If they have dementia, do you know what type? *

Does the client have any allergies? *

Do they have any communication challenges? *

Do they have any mobility needs? *

Have they had their Covid-19 vaccinations? *

Client address *

Please specify the home address of the client here.

Day club *

Free taster session date *

Please let us know what date you would like to book your free taster session for

Photo/video permission *

Emergency contact 1 - Name *

Emergency contact 1 - Number *

Emergency contact 1 - Relationship to client *

Emergency contact 2 - Name *

Emergency contact 2 - Number *

Emergency contact 2 - Relationship to client *

Email address for billing *

If different from client email, otherwise leave blank.

How will the client travel to and from the club? *

Please specify all that apply (private car, taxi, community bus etc).

Are they able to feed themselves? *

Are they able to toilet themselves? *

Does the client ever get anxious? *

Emotional Triggers *

Does the client have any emotional triggers that we need to know about?

Any tips for if client becomes unsettled? *

Client's first language? *

If more than one language spoken, please list

Client's religion? *

What did the client used to do for work? *

Do they have any family? *

Relationship to representative *

Hobbies and interests *

What do they enjoy doing? Have they previously enjoyed any hobbies or interests?

Dietary requirements/food allergies *

Does the client have any dietary requirements/food allergies?

Recent events *

Has the client recently experienced any life changing events?

Life Story *

Can you tell us anything else about their life history?

How did you hear about us? *

Deprivation of Liberty Safeguards *

Does the client have any Deprivation of Liberty Safeguards?

Mental Capacity *

Has the client had a mental health capacity assessment?

Power of Attorney - finance *

Name of P of A - finance:

Power Of Attorney - Health and Welfare *

Name of P of A - Health and Welfare:

Terms and conditions *

I agree to the Terms and Conditions

The information you enter into this form is being collected by Best Life Day Club and membermeister (we) and will be stored and processed electronically. Your personal details are required in order to contact you and, if applicable, to do business with you. This forms the lawful basis under which we collect this information; without it we cannot get in touch with you or do business with you.

By submitting this form you confirm that you understand that Best Life Day Club will store and process your personal details within GDPR guidelines.

We have a legal duty to keep your information secure and we will only use your details to provide our services to you. We will not share your information with any third party but we use third party suppliers to store your data and to help us keep it secure. We collect as little information as possible to provide our services to you.

If we no longer require the information you provided we will dispose of it securely. You have the right to access the information we hold about you and we will supply this to you in an electronic format if you ask us. You can request that we delete your personal details and we will comply with that unless we are prevented by law or other regulations, for example due to record keeping, safekeeping or accounting purposes.

Online registration form for Best Life Day Club

Use this form to register with Best Life Day Club. You will receive an email with your submission details after registration.

Contact details

Children