Connect The Dots Application Form
Please complete the form below to apply for a place at Connect The Dots!
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Name *
Date of birth *
MM
/
DD
/
YYYY
Current age *
Address *
Postcode *
Phone Number *
Email address
Tell us a little bit about your learning disability *
Do you have any medical issues, allergies or food intolerances that we should know about? *
Do you have any behavioural issues, or problems following instructions that we should know about?
 *
Do you have any issues with your mental health that we should know about? *
How many  days a week would you like to attend Connect The Dots? *
Required
What days are you free to attend Connect The Dots? Please tick all days you could attend so that we can check availability *
Required
Please tell us your preferred start date if you have one in mind. If not, we can arrange this with you so leave it blank.
Which activities are you interested in? Please tick all that you would enjoy! *
Required
Are there any other activities that you would enjoy, that aren't mentioned here?
Do you have any spent, or unspent criminal convictions? If yes, please provide us with more detail about this. *
From time to time we take photos of activities and members of our centre for marketing and advertising purposes. Are you happy to be featured in our advertising and social media campaigns? *
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