City of Joondalup Carers Community Outreach Program -Wellness Workshops Expression of Interest Parent/Carer Name * First Name Last Name Email * Contact Phone Number * Gender Age * Under 18 18-24 years old 25-34 years old 35-45 years old 46-54 years old 55-64 years old 65-74 years old 75 years or older What is the postcode where you live? * Are you from an Aboriginal and / or Torres Strait Islander background? * Yes No Prefer not to say Are you from a Culturally and Linguistically Diverse background? * Yes No Prefer not to say Are you a parent / carer (unpaid) of a person who has a disability, medical condition, mental illness or is frail and aged? * If yes, what is their age? Do you have a child enrolled in an All Stars for Autism program? * Does you have any medical conditions, dietary requirements or allergies? If yes, please provide details * What do you hope to gain by attending a Wellbeing Workshop? Name of Emergency Contact * First Name Last Name Emergency Contact Phone Number * Consent to use images (optional) * You agree that All Stars for Autism Incorporated may take photographs and video footage of you undertaking activities and use it for the purposes of marketing and promotion of All Stars for Autism Incorporated and its goods or services. This may include printed and digital marketing, including the use of your image on social media platforms. Yes No Exclusion of Liability * This agreement releases All Stars for Autism Inc. from all liability relating to injuries that may occur during All Stars for Autism’s events. By signing this agreement, I agree to absolve All Stars for Autism Inc. from all liability however arising, from injury or damage however caused, arising out of my membership and/or participation in any All Stars for Autism activity. Yes No Privacy Policy * Do you agree to the All Stars for Autism Privacy Policy https://www.allstarsforautism.org.au/privacy-policy Yes No Full Name * By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form. First Name Last Name Date * MM DD YYYY Thank you for registering for the City of Joondalup Carers Community Outreach Program Wellness Workshops. We will be in touch soon!
