Care Matters – Workshop – Upper Hutt

Name *

Email *

Phone *

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

How did you find out about us? * Select ... Carers NZ Family / Friend NASC P2P SAMS School Other

What do you want to learn from attending? *

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

What is your age group? * Select ... 20-29 30-39 40-49 50-59 60-69 70+

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

What is your ethnicity? *

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

Do you have any dietary requirements? *

Do you require any assistance to attend (i.e. interpreter, etc) * Select ... Yes No

What is the purpose of this form?
To provide non-identifiable statistical information to Disability Support Services (DSS) to create a clearer picture of who is accessing Care Matters workshops. DSS acknowledges that under the Health Information Privacy Code (1994) all information will be received in the strictest confidence.

I consent to my submitted data being collected and stored as outlined by DSS. * I understand some photos may be taken for promotional purposes. *