Nurturing the Carer – Application Form
Thank you for your interest in the Nurturing the Carer course. This program is designed to support, educate, empower, and connect carers in a safe, nurturing environment.
Personal Details
Full Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
*
-
Area Code
Phone Number
Email Address
example@example.com
Caring Role
Who do you care for?
Child
Parent
Sibling
Partner
Friend
Other
Is the caring role unpaid?
*
Yes
No
How long have you been in this caring role?
*
Do you provide:
*
Full-time care
Part-time care
Occasional / respite care
Other
Support Needs & Goals
What are the main challenges you experience as a carer?
What do you hope to gain from this course? (tick as many as apply)
*
Strategies for self-care
Connection with other carers
Practical tools for managing stress
Building confidence as a carer
Other
Accessibility & Participation
Do you have any accessibility needs (physical, sensory, communication, etc.)?
*
No
Yes
If you selected 'yes' above, please provide details:
Do you require support with transport or respite to attend?
*
No
Yes
If you selected 'yes' above, please provide details:
Course Commitment
The course runs for 8 weeks during Term 4, on a Wednesday, with weekly sessions of 2 hours, from 9.30am-11.30am. Are you able to commit to attending all sessions?
*
Yes
No
If you selected 'no' above, please provide details:
Emergency Contact
Full Name
*
First Name
Last Name
Relationship
*
Phone Number
*
-
Area Code
Phone Number
Declaration
I declare that the information provided is true and correct.
Signature
*
Date
*
-
Day
-
Month
Year
Date
For questions, call: Navigating Disability 1300 665 773 or Infinitely Valued 0418 242 534
Submit
Submit
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