fbpx

T: 01438 729461
M: 07748 690989
E: This email address is being protected from spambots. You need JavaScript enabled to view it.
Office hours: 9.00am to 3.00pm

Member Registration Young Adults Over 18

 

Where are you a resident?

To create an account please enter a username, email and password below...

Username:
Email:
Password:
Full Name:
Address:
Postcode:
Mobile/SMS:
Date of Birth:
Are you...?
Where do you go to school/college/work?:
My hearing loss is...
My communication:
If other:
I use:
If other:
Essential Medical Information: (e.g. diagnosis, allergies, seizures, asthma)

Please tell us some more about you, such as; Your hobbies (what you like to do), if you like animals, sport, cooking etc :
Who do you live with:
Do you travel independently (use trains and buses on your own)?

How can Phoenix help you most?
If other:
How do you know about Phoenix?
You know people who come
A Parent/Guardian told you
NDCS
Audiology
Teaacher of the Deaf
School
College

If other:
Do you want to join our Phoenix Plus WhatsApp Group?

Photo Consent


We require your consent before we use photos that others will view. For example, our annual yearbook, on our website and social media and funders may also like to see them for evidence.

I DO GIVE permission to be photographed and for images to be used for publicity purposes by The Phoenix Group or by our funders. Photos that contain images of me may also be displayed on our Facebook page.

I DO NOT GIVE give permission to be photographed for publicity or any other purposes by The Phoenix Group for Deaf Children

Transport Consent


We may need to provide transport for an activity for your child. In these circumstance, we would need parental consent if they are under the age of 16 years. Please tick yes/no to consent to transport.

YES I do give transport consent.

NO I do not give transport consent.

Emergency Contact Details


Name of Person 1:
Relationship to you (Mum, Dad, etc):
Mobile Number:
Method of Contact:
Name of Person 2:
Relationship to you (Mum, Dad, etc):
Mobile Number: Method of Contact:
Are you on low income and in receipt of Universal Credit (Not PIP or DLA)?

If Yes, please provide details:

This information helps us to understand which families may be entitled to some subsidised activities and food vouchers from Hertfordshire County Council.

Below is information that we need to collect as required by our funders. Please use one tick for each member of your family. Please complete all sections.

Ethnic background of parents/carer and children (each tick = a family member)

White
English/Scottish/Welsh/Irish/Northern Irish
Gypsy or Irish Traveller
Any other white background

Asian
Mixed ethnic background
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background

Black/African/Caribbean/Black UK
English/Scottish/Welsh/Irish/Northern Irish
African
Caribbean
Any other Black/African/Caribbean background

Other ethnic Group
Arab
Any other
Religion or belief (each tick = a family member)

No religion
Christian
Buddhist
Hindu
Jewish
Muslim
Sikh
Other religion
Prefer not to say
I agree to the terms & conditions