Tick the box next to your chosen workshop(s) *Brisbane Outsider ArtistsProfessional Artists' WorkshopMixed Media Visual Arts - MorningMixed Media Visual Arts - AfternoonOne-on-one MentoringPersonal DetailsName *FirstLastDate of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone *Email *Do you identify as Aboriginal or Torres Strait Islander? *YesNoDo you have an NDIS Plan? *YesNoUnsureResidential AddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeAlternative/Emergency ContactFull NameRelationshipPhone NumberEmailSecondary Contact NumberHow would you prefer to receive information? *EmailPostPhoneAlternate ContactAccess and Support Do you identify as a person experiencing disability? *YesNoPrimary diagnosis/disability *Additional diagnoses/conditions: *Do you have epilepsy? *YesNoDo you have an Epilepsy Management Plan? *YesNoDo you have asthma? *YesNoDo you have an Asthma Management Plan? *YesNoDo you have problems swallowing medication, eating or drinking? *YesNoDo you have a Meal Management Plan? *YesNoDo you have problems with you vision? *YesNoDescribe any problems with vision:Do you have problems with your hearing? *YesNoDescribe any problems with hearing:Do you require an interpreter? *YesNoDo you have any allergies? *YesNoList any allergiesDo you need assistance with transfers? *I don't need assistance1-person assist / supervision2-person assist2+ person assistWhat is your main method of mobility? *Walk independently with or without aidWalk with assistance or supervisionIndependent use of wheelchairAssisted use of wheelchairIdentify any mobility equipment that you currently usePower wheelchairManual wheelchairWalking frameWalking stick/crutchesFloor hoistCeiling hoistWhat is your main method of communication? *VerbalSigningSpeech generating devicePODD bookCommunication boardGesturingDo you have any behaviours of concern? *YesNoDo you have a Positive Behaviour Support Plan (PBSP)? *YesNoAre you subject to Restrictive Practices (RP)? *YesNoType of RPHow 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. NameSubmit