Name *

First Name

Last Name

Gender *

Male

Female

Other

Date of Birth *

Month, Day, Year.

MM

DD

YYYY

Return Contact *

Please tick any of the boxes below so we know how you'd prefer us to get back in contact with you. You may tick more than one box.

Telephone

Text Message

Email

Please tick the statement most appropriate to you: *

I have a learning disability

I have an autistic spectrum disorder

I have an acquired brain injury

Other

Please check the statements that apply *

I am not confident around dogs

I am confident around small dogs

I am confident around medium sized dogs

I am confident around large dogs

I am confident walking a dog that does not pull on the lead

I am confident walking a dog that does pull on the lead

Please tell us why you would like to attend Barks & Recreation: *

For fun/leisure

Meet new people

To learn and gain new skills

For qualifications

To help me into voluntary or paid work

Do you wish to attend Barks & Recreation with your own carer? *

We are experienced and trained social care workers that support people to walk dogs. We are unable to provide support for additional care needs such as personal care or with administering medication. Should you require additional support during a walk you will need to attend with your own carer.

Yes

No

How do you plan to pay for our support? *

Our service is most commonly funded through direct payments, but other options are available.

Direct Payments

Commissioned Social Care Package

Personal Finances/Cash

I'm Not Sure

Availability *

Our supported services are very popular and there may be limited availability on specific days. Please tick the days on which you are available to attend.

Monday

Tuesday

Wednesday

Thursday

Friday

Length of Session Per Day *

Half Day (between 2.5 and 4 hours)

Full Day (between 6 and 9 hours)

Approximate Time *

At what times would you be available to attend? You may tick more than one box.

Morning (between 9am and 1pm)

Lunch (between 10.30am and 2.30pm)

Afternoon (between 1pm and 5pm)

Disclaimer *

I am aware that Barks & Recreation staff members are not able to administer any medication or attend to any personal care needs. Should I attend Barks & Recreation with a carer I acknowledge that they are responsible for any of my care needs beyond the safe walking of the dog. Should I attend Barks & Recreation without a carer I am in agreement that by attending I do not normally require any additional care needs beyond the safe walking of the dog. I am in agreement that I am in a suitable condition to undertake the role expected of me at Barks & Recreation. I declare that all information given above is accurate to the best of my knowledge. I acknowledge that a series of control measures and risk assessments are in place for the safety of myself, the dog and others and must be followed to ensure everybody at Barks & Recreation is kept as safe as possible. While every effort is made to keep everyone safe I accept that dogs can at times display unpredictable behaviour which may lead to personal injury and do not hold Barks & Recreation responsible for any injury that occurs to myself due to this.

I understand and agree to the above.

Notice of Cancellation *

We politely ask that people using the service give two weeks notice prior to cancelling any sessions, if possible. Cancelling within a 14 day period of the session will incur the full cost of the session to be paid.

I have read and agree to the terms above.