Grandcarers SA New Client Registration Form

New Client Registration Form
Important information

Grandcarers SA needs to collect your personal information to provide our services to you. Australian privacy law allows us (Grandcarers SA) to use or disclose your personal information for the reason we have collected it. Grandcarers SA cannot use or disclose your personal information for another reason (a secondary purpose) unless an exception applies. Exceptions include:
- you’ve consented to Grandcarers SA using or disclosing your personal information for a secondary purpose and we will ask you to authorise this information
- Grandcarers SA uses or discloses your personal information because they think it’s reasonably necessary for enforcement-related activities carried out by, or on behalf of, an enforcement body
- a secondary purpose is required or authorised under an Australian law, or court or tribunal order.
1. Personal details (Client 1)
Client 1 - First name:
Your first name:
Client 1 - Family name:
Your family name:
Client 1 - Date of birth:

DayMonthYear
Client 1 - Mobile phone number:
Client 1 - Email address
example@example.com
Client 1 - Address

Street Address

Street Address Line 2

Suburb/CityState

Postcode

Client 1 - Cultural identity:

Rows	Check
Aboriginal
Torres Strait Islander
Culturally and linguistically diverse (CALD)
Other
None of the above

Client 1 - If 'CALD' or 'Other' please specify:
Client 1 - Your country of birth:
Client 1 - Language spoken at home:
Client 1 - Do you require an interpreter?
2. Partner or co-parent (Client 2)

(IF APPLICABLE)
Client 2 - Their first or given name:
Client 2 - Their last or family name:
Client 2 - Date of birth:

DayMonthYear
Client 2 - Mobile phone number:
Client 2 - Email address:

Client 2 - Cultural identity:

Rows	Check
Aboriginal
Torres Strait Islander
Culturally and linguistically diverse (CALD)
Other
None of the above

Client 2 - If 'CALD' or 'Other' please specify:
Client 2 - Their country of birth:
Client 2 - Their relationship to you:
3. I am / we are

Rows	Check
Primary carer(s) for my / our grandchild or grandchildren
Primary carer(s) for a family member's / friend's child or children
Alienated from my / our grandchild or grandchildren
Concerned for my / our grandchild or grandchildren

If you are alienated from your grandchild or children, or have care concerns please provide details:
4. Child or children in your care

CHILD 1
Child 1 - First or given name:
Child 1 - Last or family name:
Child 1 - Date of birth:

DayMonthYear
Child 1 - Their relationship to you:
e.g. maternal grandchild
Child 1 - Are they a NDIS participant?
Select yes or no

Child 1 - Medical information:

Rows	Check
Diagnosed intellectual / mental health condition or behaviours of concern.
Undiagnosed intellectual / mental health condition or behaviours of concern.
Neurodivergent or other specific learning disability (e.g., dyslexia, dysgraphia, dyscalculia, autism spectrum disorder or attention-deficit / hyperactivity disorder).

Child 1 - Please provide details:

Child 1 - Their cultural identity:

Rows	Check
Aboriginal
Torres Strait Islander
Culturally and linguistically diverse (CALD)
Other
None of the above

Child 1 - If 'CALD' or 'Other' please specify:

Child 1 - Care arrangement:

Rows	Check
Informal
DCP Kinship Order(s)
Family Court Order(s)

Child 1 - Please provide details:
Child 1 - Healthcare Card number:
If applicable
Child 1 - Medicare Card number:
Child 1 - DCP Kinship ID Card number
If applicable
Child 1 - Medicare Individual Reference number:
This is the number to the left of the name on the card.
Child 1 - Date they came into your care:

DayMonthYear
Child 1 - Other relevant information:

CHILD 2
Child 2 - First or given name:
Child 2 - Last or family name:
Child 2 - Date of birth:

DayMonthYear
Child 2 - Their relationship to you:
e.g. maternal grandchild
Child 2 - Are they a NDIS participant?
Select yes or no

Child 2 - Medical information:

Rows	Check
Diagnosed intellectual / mental health condition or behaviours of concern.
Undiagnosed intellectual / mental health condition or behaviours of concern.
Neurodivergent or other specific learning disability (e.g., dyslexia, dysgraphia, dyscalculia, autism spectrum disorder or attention-deficit / hyperactivity disorder).
Other issues that may impact upon care arrangements or the kind of supports required (e.g., medical issues, difficulty with cognition, mobility or vision, difficulty performing daily tasks such as eating, dressing or personal care).

Child 2 - Please provide details:

Child 2 - Their cultural identity:

Rows	Check
Aboriginal
Torres Strait Islander
Culturally and linguistically diverse (CALD)
Other
None of the above

Child 2 - If 'CALD' or 'Other' please specify:

Child 2 - Care arrangement:

Rows	Check
Informal
DCP Kinship Order(s)
Family Court Order(s)

Child 2 - Please provide details:
Child 2 - Healthcare Card number:
If applicable
Child 2 - Medicare Card number:
Child 2 - DCP Kinship ID Card number
If applicable
Child 2 - Medicare Individual Reference number:
This is the number to the left of the name on the card.
Child 2 - Date they came into your care:

DayMonthYear
Child 2 - Other relevant information:

CHILD 3
Child 3 - Their first or given name:
Child 3 - Their last or family name:
Child 3 - Their date of birth:

DayMonthYear
Child 3 - Their relationship to you:
e.g. maternal grandchild
Child 3 - Are they a NDIS participant?
Select yes or no

Child 3 - Medical information:

Rows	Check
Diagnosed intellectual / mental health condition or behaviours of concern.
Undiagnosed intellectual / mental health condition or behaviours of concern.
Neurodivergence or other specific learning disability (e.g., dyslexia, dysgraphia, dyscalculia, autism spectrum disorder or attention-deficit / hyperactivity disorder).
Other issues that may impact upon care arrangements or the kind of supports required (e.g., medical issues, difficulty with cognition, mobility or vision, difficulty performing daily tasks such as eating, dressing or personal care).

Child 3 - Please provide details:

Child 3 - Their cultural identity:

Rows	Check
Aboriginal
Torres Strait Islander
Culturally and linguistically diverse (CALD)
Other
None of the above

Child 3 - If 'CALD' or 'Other' please specify:

Child 3 - Care arrangement:

Rows	Check
Informal
DCP Kinship Order(s)
Family Court Order(s)

Child 3 - Please provide details:
Child 3 - Healthcare Card number:
If applicable
Child 3 - Medicare Card number:
Child 3 - DCP Kinship ID Card number
If applicable
Child 3 - Medicare Individual Reference number:
This is the number to the left of the name on the card.
Child 3 - Date they came into your care:

DayMonthYear
Child 3 - Other relevant information:

CHILD 4
Child 4 - Their first or given name:
Child 4 - Their last or family name:
Child 4 - Their date of birth:

DayMonthYear
Child 4 - Their relationship to you:
e.g. maternal grandchild
Child 4 - Are they a NDIS participant?
Select yes or no

Child 4 - Medical information:

Rows	Check
Diagnosed intellectual / mental health condition or behaviours of concern.
Undiagnosed intellectual / mental health condition or behaviours of concern.
Neurodivergence or other specific learning disability (e.g., dyslexia, dysgraphia, dyscalculia, autism spectrum disorder or attention-deficit / hyperactivity disorder).
Other issues that may impact upon care arrangements or the kind of supports required (e.g., medical issues, difficulty with cognition, mobility or vision, difficulty performing daily tasks such as eating, dressing or personal care).

Child 4 - Please provide details:

Child 4 - Their cultural identity:

Rows	Check
Aboriginal
Torres Strait Islander
Culturally and linguistically diverse (CALD)
Other
None of the above

Child 4 - If 'CALD' or 'Other' please specify:

Child 4 - Care arrangement:

Rows	Check
Informal
DCP Kinship Order(s)
Family Court Order(s)

Child 4 - Please provide details:
Child 4 - Healthcare Card number:
If applicable
Child 4 - Medicare Card number:
Child 4 - DCP Kinship ID Card number
If applicable
Child 4 - Medicare Individual Reference number:
This is the number to the left of the name on the card.
Child 4 - Date they came into your care:

DayMonthYear
Child 4 - Other relevant information:

Rows	Yes	No
I give authority for Grandcarers SA to use identifiable photographs of me.
I give authority for Grandcarers SA to send me information or carer support related opportunities by post, email or SMS. (You can always opt out).
I give authority for Grandcarers SA to collect, store, use and disclose personal and sensitive information, including health records, for the primary purpose of providing me with services and support.
I request that Grandcarers SA contact me as the guardian / representative of a child in my care to discuss any events.
I agree that if my caring circumstances change, I will advise Grandcarers SA as soon as possible.

Rows	Check
Referral from an organisation
Referral from someone
Social media
Our website
Media (radio, TV, newspaper)
Self referral

New Client Registration Form

1. Personal details (Client 1)

2. Partner or co-parent (Client 2)

3. I am / we are

4. Child or children in your care

5. Consent to collect, use and retain personal information