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APPLY TO STAY AT THE RIPPLE RETREAT

Applicant’s Details

DATES REQUESTED

(Saturday 11am to Wednesday 12noon. Shorter stays are possible but must always start on a Saturday at 11am)

Applicant's Name

First Name

Last Name

Relationship to Child / Young Person

Applicant's Age

Applicant's Phone Number

Applicant's Email

Applicant's Full Address (including post code)

Car reg no. and please state if you require the electric car charger

YOUNG PERSON'S DETAILS

Young Person's Name

First Name

Last Name

Young Person's Gender

Young Person's Date of Birth

Young Person's Age

Young Person's Diagnosis

Date of Diagnosis / Relapse

Currently on Active Treatment

Yes

Date of Last Active Treatment (if applicable)

PROFESSIONAL SUPPORT TEAM DETAILS

We require to contact the Professional Support Team that provided care to your child in order to confirm your eligibility to stay at the Ripple Retreat.

Treatment Centre / Hospital Name

Ward

Nurse Specialist's Name

Nurse Specialist's Location

Nurse Specialist's Contact Number

Nurse Specialist's Email Address

Social Worker's Name

Social Worker's Location

Social Worker's Telephone Number

Social Worker's Email Address

FAMILY DETAILS

Please note that the Ripple Retreat can only accommodate a maximum of five people from your household, including the applicant. Please list their details below.

Additional Family Member 1

First Name

Last Name

Additional Family Member 1's Relationship to Young Person

Additional Family Member 1's Age

Additional Family Member 2

First Name

Last Name

Additional Family Member 2's Relationship to Young Person

Additional Family Member 2's Age

Additional Family Member 3

First Name

Last Name

Additional Family Member 3's Relationship to Young Person

Additional Family Member 3's Age

We require prior knowledge of any accessibility requirements to ensure that we can accommodate your family (including details of any equipment or registered assistance dogs). Please also let us know if you have any young infants in your family and if you require, for example, a highchair or travel cot.

Accessibility / Additional Requirements:

PRIVACY NOTICE

The personal data provided to us in the application form will be processed in accordance with the privacy notice at the foot of this page.. In particular, please note that there are CCTV cameras that are operational at the Ripple Retreat and remotely monitored for your safety and for the security of the Ripple Retreat.

TERMS AND CONDITIONS

By signing and submitting this application form to It's Good 2 Give!, you agree to comply with the terms and conditions at the foot of this page. Please ensure you have read these terms in full before submitting this application form. If you have any queries regarding the terms and conditions, please let us know.

I can confirm all of the information provided in this form is complete and accurate, and I have read and understood the terms and conditions that apply to my application.

NAME

DATE

It’s good 2 give Ripple Retreat - Privacy Notice

It’s good 2 give Ripple Retreat - Terms & Conditions

If you have any questions regarding any part of this form please email carla@itsgood2give.co.uk

APPLY TO STAY AT THE RIPPLE RETREAT

Applicant’s Details

It’s good 2 give Ripple Retreat - Privacy Notice

It’s good 2 give Ripple Retreat - Terms & Conditions

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It's good 2 give! is a registered charity number Sc041416
Company limited by guarantee number SC376977
Registered Address: Ripple Retreat, Invertrossachs Rd, Callander. FK17 8HG.