ILC Term 2 program registration

ILC Term 2 program registration

Term 2 2025
Full Name*

First NameLast Name
Residential postcode
Phone Number*
E-mail*
example@example.com
Which program would you like to register for?*
Which do you identify as? (You will not be asked to provide any evidence)*

Living with disability or mental health challengeParent / family of someone living with disability or mental health challengeCarer of someone living with disability or mental health challenge
Do you consent to having your picture taken and published?

YesNoOnly if you cannot see my face
Do you have any additional physical requirements?

YesNo
Please Note: This information will be kept confidential and entered into a secure electronic filing system to be used for program information sharing, covid tracing and emergency contact if required. This information will not be sold under any circumstances. This information will not be shared without the permission of the owner except where required by law, in particular, under the children and young persons (care and protection) act 1998.

We are required to provide some data to our funding body via the Department of Social Services Data Exchange System (DEX). This is used to show the need of and analyse our services and to assist in planning for futre funding. We would like your permission to share your information for this purpose.

I understand that HNS ILC will keep my information confidential, i give my permission for all of the above information as relates to myself and my children, to be entered into Department of Social Services Data Exchange (DEX) systemd and kept for program outcome reporting purposes with the Department of Social Services.
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