Interested in joining MMAD?
Name of Participant
*
Participant First Name
Participant Last Name
Birth Date
*
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Year
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birth Date
*
-
Day
-
Month
Year
Date
Participant Mobile Number
*
-
Area Code
Phone Number
Participant E-mail
*
Is the participant of Aboriginal and/or Torres Strait Islander origin?
*
Yes
No
MMAD Location
*
NSW
Participant Preferred Gender Pronoun:
*
He/Him
She/Her
They/Them
1.How happy are you with your life as a whole?
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Very sad
Very happy
0 is Very sad, 10 is Very happy
2. How happy are you about the things you have? Like the money you have and the things you own?
*
0
1
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Very sad
Very happy
0 is Very sad, 10 is Very happy
3. How happy are you with your health?
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0
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Very sad
Very happy
0 is Very sad, 10 is Very happy
4. How happy are you with the things you want to be good at?
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0
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Very sad
Very happy
0 is Very sad, 10 is Very happy
5. How happy are you about getting on with the people you know?
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0
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Very sad
Very happy
0 is Very sad, 10 is Very happy
6. How happy are you about how safe you feel?
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0
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Very sad
Very happy
0 is Very sad, 10 is Very happy
7.How happy are you about doing things away from your home?
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0
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10
Very sad
Very happy
0 is Very sad, 10 is Very happy
8.How happy are you about what may happen to you later in life?
*
0
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10
Very sad
Very happy
0 is Very sad, 10 is Very happy
Referrer Name (if applicable)
Referrer First Name
Referrer Last Name
Permission to contact referrer
Yes
No
Referrer Email
example@example.com
Referrer Phone Number
Referrer Phone Number
-
Area Code
Phone Number
EMERGENCY/MEDICAL INFORMATION
Parent 1/Guardian's Details
*
Parent 1/Guardian First Name
Parent 1/Guardian Last Name
Parent 1/Guardian Email
example@example.com
Parent 1/Guardian Phone Number
Parent 1/Guardian Phone Number
*
-
Area Code
Phone Number
Parent 2/Guardian's Details
*
Parent 2/Guardian First Name
Parent 2/Guardian Last Name
Parent 2/Guardian Email
example@example.com
Parent 2/Guardian Phone Number
*
-
Area Code
Phone Number
Parent 2/Guardian Phone Number
The participant's insurance provider is:
My insurance provider is
The participant's medical provider is:
My medical provider is
Reference number on Medicare card:
The participant is taking the following medications:
My child is taking the following medications
My child has the following allergies
The participant has the following allergies:
I would like to contribute towards MMAD's charitable programs for myself/my child:
Use my Creative Kids voucher
Use my NDIS plan
Creative Kids voucher number
I would like to make a donation
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AUD
Donation direct to MMAD
Credit Card/Debit Card
I AGREE TO THE FOLLOWING Parent/Guardian release is required if you are under 18 years of age.
*
AUDIO VISUAL AGREEMENT: Parent/Guardian release is required if you are under 18 years of age.
*
I authorise MMAD to publicly use audio visual content of me/my child to highlight and promote MMAD in any form of publication, production or presentation at their discretion. I also acknowledge that MMAD is not responsible for any release of public content by third parties.
*
Signature
*
Date of completion:
*
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Month
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Date
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