Tick the box next to your chosen workshop(s) *

Theatre & Dance Ensemble
Rhythm Circle
Access Arts Singers

Personal Details

Name *

First

Last

Date of Birth *

Phone *

Email *

Do you identify as Aboriginal or Torres Strait Islander? *

Yes
No

Do you have an NDIS Plan? *

Yes
No
Unsure

Residential Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Alternative/Emergency Contact

Full Name

Relationship

Phone Number

Email

Secondary Contact Number

How would you prefer to receive information? *

Email
Post
Phone
Alternate Contact

Access and Support

Do you identify as a person experiencing disability? *

Yes
No

Primary diagnosis/disability *

Additional diagnoses/conditions:

Do you have epilepsy? *

Yes
No

Do you have an Epilepsy Management Plan? *

Yes
No

Do you have asthma? *

Yes
No

Do you have an Asthma Management Plan? *

Yes
No

Do you have problems swallowing medication, eating or drinking? *

Yes
No

Do you have a Meal Management Plan? *

Yes
No

Do you have problems with you vision? *

Yes
No

Describe any problems with vision:

Do you have problems with your hearing? *

Yes
No

Describe any problems with hearing:

Do you require an interpreter? *

Yes
No

Do you have any allergies? *

Yes
No

List any allergies

Do you need assistance with transfers? *

What is your main method of mobility? *

Identify any mobility equipment that you currently use.

What is your main method of communication? *

Do you have any behaviours of concern? *

Yes
No

Do you have a Positive Behaviour Support Plan (PBSP)? *

Yes
No

Are you subject to Restrictive Practices (RP)? *

Yes
No

Type of RP

How did you hear about us? *

Terms

At Access Arts we love to celebrate the work of our members so we we may use photographs, video and other media to spread the word! Please contact us on 07 3505 0311 if you are not comfortable with us documenting you or your work.

In compliance with Access Arts' risk management and insurance procedures, this enrolement form must be submitted BEFORE commencing any Access Arts workshop or program.