Application to Become a Co-Worker at Lauriston Farm All information supplied is covered by our Data Protection Policy which can be viewed at http://www.lauristonfarm.co.uk/setting-up-a-placement.html About you Forename: Surname: Chosen name: Date of Birth: Address: Telephone number: Mobile: Email: Post Code: Which farm days are you interested in? Please tick box: Tuesday Crafts Wednesday Farming Thursday Horticulture Please tell us if you have had previous experience in your chosen days (you do not need to have had any previous experience in your chosen farm days to become a co-worker).
Who is helping you set up your placement? Name: Contact number: Relationship to you: Do you have a Personal Support Worker (or one-toone worker): Yes No Please give details of your Social Worker or Care Manager if you have one: Name: Address: Who would pay for your placement?
Is there any specific support you need while at Lauriston Farm? Please tell us about any dislikes or worries you want us to be aware of: Getting to the farm Please tick the box(es) below to tell us how you would travel to and from the farm: Bicycle Bus Public transport Car Taxi Walk Do you require a local pick up? Yes No
About your food needs and preferences If you have any special dietary needs and preferences please tell us about them here: Will you be bringing a packed lunch or eating a lunch supplied at the farm? Please tick box: Packed lunch Farm lunch Do you require special cutlery? Yes No Do you have any food allergies? Yes No If yes, please tells us which food (s) you are allergic to:
Communication How do you like to communicate? Please tell us how you prefer to communicate. For example, do you prefer spoken word, signing, symbols or another form of communication? If your first language is not English, please let us know.
Help and assistance We aim to help each other. Is there anything you need or any extra help you require? Religion If you have religious beliefs and would like us to be mindful of them, please give the name of your religion in the space below: Any other information Have we missed something? Please tell us of any other information you think would be useful for us to know about you:
Sharing photographs and videos Photos and videos are a good way of showing life on the farm and what you do. Sometimes they may be used in publicity or on the website. Please tick the box next to any of the statements below you agree with: I am happy to have photos taken of me at work on the farm I am happy for these photos to be used in publicity for the farm I am happy for these photos to be shared on the farm s website I do not want to have photos taken of me at work on the farm I do not want photos of me used in publicity for the farm or put on the farm s website I do not want photos of me to be shown publicly, but I may be happy for photos of the craftwork I do to be shown publicly. Please ask me first!
Sharing of photos: Please do not share photos on Facebook etc without asking the permission of those in the photo. Data Protection Act 1998: This information will be kept in a safe place and only shared with the farm management team. Signed: Dated: Thank you for applying to become a co-worker at Lauriston Farm. Thank you for taking time to fill in this form, please bring it, and the medical form, when you first come to the farm or on your taster day.