Registration Form 2020

Registration Form

Please complete participant information below:
Name *

First Name Last Name
Birth Date

Day Month Year
How would you identify your gender?
Address *

Street Address

Street Address Line 2

City

Postal / Zip Code
E-mail *
Mobile Number *
Phone Number
Which project are you interested in? *
Interested in more than one project? Tell us here:
Tell us about your neurodiversity *
Other (please specify)
If you can't see something that describes you, please tell us a little more about your neurodiversity here.
Tell us about any medical conditions/allergies/support needs we should be aware of *
Do you have to take medication? Are you allergic to any food? Do you sometimes need a quiet space? Do you have any sensory likes or dislikes? We like to make sure we can support you the best we can in our projects so please write anything that would help you feel more comfortable here.
I give my consent for Starling to collect and store my personal information so that I can be contacted about future projects. Starling will never share your personal details with others and will keep all your data secure. *

Yes, I am happy to be contacted (participant)
Parent/Carer/Referrer Info:

Please provide your details if you are completing this form on behalf of a participant/young person
Name

First Name Last Name
E-mail
example@example.com
Mobile Number
Phone Number
I give my consent for Starling to collect and store my personal information so that I can be contacted about future projects. Starling will never share your personal details with others and will keep all your data secure.

Yes, I am happy to be contacted (parent/carer/referrer)
Should be Empty:

Registration Form

Parent/Carer/Referrer Info: