Palmerston North Care Matters Adulthood Workshop

Name *

Email *

Phone *

Region * Select ... Auckland Bay of Plenty Canterbury Christchurch Hawkes Bay Kapiti Coast Manawatu Nelson Northland Otago Southland Taranaki Tasman Taupo Waikato Wairarapa Wellington West Coast

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

How did you find out about us? * Select ... Family / Friend Social media Database email School Parent to Parent NASC SAMS Carers NZ 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+

Birth year of person 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, understand that this includes being added to the database, and acknowledge that some photos may be taken for promotional purposes. *