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 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

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

Do you have any dietary requirements (if applicable) *

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 .