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Cojac Centre

Caring Operations Joint Action Council (COJAC) is a voluntary managed Scottish Charity Incorporated Organisation (SCIO) registered with the Office of the Scottish Charity Regulator and Care Inspectorate Scotland.

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Adults Registration Form

Evening Group Registration Form 2025

Name (required) *

Date of Birth (required) *

Street Address (required) *

City (required)

Postcode (required)

Mobile Number (required) *

Telephone Number

Email (required) *

Do you have a Guardianship Order?YesNo

If yes please provide contact details below:

Do you need an interpreter? (required) *

Please list any services currently received? (required) *

Diagnosis (required) *

Please give details of any medication taken (required) *

Preferred methods of communication

Preferred methods of communicationVerbal speech onlyVerbal assisted by MakatonVerbal assisted by pointing and leadingNonverbal assisted by PECS & symbolsNonverbal assisted by SignalongBSLI pad or other communication device

Preferred methods of communicationVerbal assisted by PECS & symbolsVerbal assisted by SignalongVerbal persistent questioningNonverbal assisted by MakatonNonverbal assisted by vocalisation (noises)Non verbalOther

Please specify

Barriers to communication *Echolalia/repetitive languageMonologueElective mutismMetaphorical languageNot understanding othersOther

Please state

Displays anxiety by (required) *Self-harming behaviourShouting/swearingWithdrawalAbscondingPhysical attackOther

Please state

Level of independence (required) *Needs support at all timesNeeds support on public transportNeeds support on any type of transportNeeds support access/egress any transport e.g. mini busOther

Please specify

Level of self-care skills (required) *Needs support with all self-careNeeds reminders for the toiletNeeds help with feedingIn pads or nappiesNeeds help to go to toiletOther

Please specify

What is reaction to group settings (required) *Once settled is at ease in most groupsOnce settled is at ease with small groupsFinds groups difficultIs very unhappy in a group settingOther

Please specify

What activities are most enjoyed

What activities are most enjoyed?MusicDancingSportsReadingArts and craftsDigital/photographyOutings or trips

What activities are most enjoyed?Computer/I.T.Board gamesOutdoorsTelevision/FilmDramaAnimalsOther

Please specify

Name of Doctor (required) *

Street Address

City

Postcode

Telephone Number (required) *

Have you had a recent tetanus injection (required) *YesNo

Is there any other additional information that would be useful?

Home Contact Name (required) *

Phone No (required) *

Relationship (required) *

Email (required) *

Name of Emergency Contact (required) *(Please provide details of someone we can contact if you are unavailable)

Relationship (required) *

Street Address

City

Postcode

Telephone No (required) *

Mobile Number (required) *

Email

Name of Emergency Contact 2

Relationship

Street Address

City

Postcode

Telephone No

Mobile Number

Email

I grant consent for (required) *

Please choose (required) *To participate in indoor/outdoor activities organised by COJACTo receive emergency medical treatment, including anaesthetic as considered necessary by medical authoritiesTo be videoed/photographed for monitoring, evaluation, publicity, marketing, shows/presentations and displays within the centre.

Service Users Signature (required) *

Parent/Guardian Signature

Date (required) *

Agree (required) *

Privacy Policy

COJAC protects all personal information you provide us. We are committed to protecting your privacy and we want you to be assured that your data is managed properly by our charity. Any personal information you provide to us will be used lawfully and in accordance with this privacy policy. We respect all personal data you choose to share with us, and we will ensure it is stored safely and processed fairly and legally in accordance with the Data Protection Act (1998) and the GDPR (2018). We aim to be clear when we collect your data and throughout your involvement with us, about how we intend to use it, and will not do anything with your personal data that you wouldn’t reasonably expect as a service user and/or supporter of our charity. Developing a good relationship and better understanding of you through correct and legal use of your personal data allows us to make better decisions, fundraise more efficiently, and helps us to reach our short and long terms charitable goals of providing the very best services. We aim to track your involvement with us and build strong and helpful relationships. COJAC is a voluntary managed Scottish registered charity SC008190, which provides practical services for children, young people, adults and families and carers living with disability. We are a Data Controller and as such are registered with the Information Commissioner’s Office (The ICO). Our registration number with the ICO is A8481655. If we have the explicit and informed consent of you as an individual, or a parent or guardian of someone under 18 years, then this information may be used publicly by us, in materials promoting our work, for training, or in documents such as our annual report. We will never use full names. However, you can always change your mind about consent by emailing us at cojac@cojaccentre.co.uk.

Security

We are committed to keeping your information secure. We have put in place suitable physical, electronic and managerial procedures in place to safeguard and secure the information we collect. If you have any issues or questions about our security, please do not hesitate to contact the Centre Manager.

Print Name (required) *

Signed (required) *

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Please do not fill in this field.

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Address
146 Castlemilk Dr
Glasgow
G45 9UB

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