Name *

Email *

Town *

Phone number *

Are you new to Care Matters? * Select ... Yes No

In what capacity are you attending? * Select ... Family Friend Other

What session time would you like to attend? * 9.30am - 11.45am
12.30pm - 2.30pm

What is your age group? * Select ... 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99

What is your ethnicity? * Select ... NZ European NZ Maori Samoan Tongan Niuean Chinese Indian Other

Do you require any additional support to attend? * Select ... Yes No

What is the main type of disability the person you live with/care for has? * Select ... Autism Intellectual Physical Sensory Multiple Disabilities Other

What is the age of the person being cared for? *

Do you/your family qualify for disability supports services or EGL supports? * Select ... Yes No

What do you want to learn from attending? *

Would you like Care Matters to inform you of any future events? Select ... Yes No

For catering purposes, do you have any dietary requirements?

What is the purpose of this form?

To provide non-identifiable statistical information to the Ministry of Health to create a clearer picture of who is accessing Care Matters face-to-face training. The Ministry of Health acknowledges that under the Health Information Privacy Code (1994) all information will be received in the strictest confidence.

I agree *

I consent to my submitted data being collected and stored as outlined by the site .