LOOK UK and Jamie's Farm Activity Week

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All information collected in this form is stored confidentially and solely for the use of accommodating all possible needs of participants and to identify staffing needs. It is important that you read the questions carefully and answer as honestly as possible.
Please note that completion of this application form does not guarantee your place at the activity week.
A member of LOOK staff will be in touch with you in due course to discuss your application.

Personal details:

Please complete these details as/on behalf of the young person applying to attend the activity.

First name:

Surname:

Are you already a LOOK mentee?

YesNo

Preferred pronouns:

He / himShe / herThey / themOther

For this event, participants will be sharing a room with same sex individuals. Please tick below to show you consent to this. If you would like to discuss this further, please contact Elin at elin@look-uk.org

I consent to sharing a room with same sex individuals

Date of birth

Email:

Mobile Number: (If young person has one)

Address:

Post code:

Emergency contact full name:

Emergency contact relation to you:

Emergency contact phone number:

Emergency contact email:

Your first language:

Preferred format: (Please note that there will be forms to complete prior to and after the event).

What is the name of your eye condition and at what age were you diagnosed?

I would describe my level of sight as:

Blind / SSIPartially sighted / SIOther

Please give us information about your level of mobility in everyday situations, e.g. getting around, steps or poor light conditions

Please give details of any specialist equipment and technology you use:

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General Information

To help us plan our activities and staffing levels, please describe your ability in the following areas

Your personal independence:

Your social skills and how you find working in a group:

How you meet new challenges in an unfamiliar environment:

Your level of self-esteem:

Why did you choose to apply to this activity? What do you hope to gain from the experience?

Is there anything else you would like us to know in preparation for this event?

LOOK UK and Jamie's Farm Activity Week - Application Form

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