Workshop Registration Form

Workshop Location*

Workshop Date*

Name*

Phone*

Email*

Region you live in*

Address*

New to Care Matters*

What do you want to learn from attending?

How did you find out about us?*

Other (please state)

In what capacity are you attending?

Other (please state)

What is your age group?

What is your ethnicity?

Other (please state)

Do you require any additional support to attend our workshop e.g. do you have a visual impairment?

What is the main type of disability the person you live with/care for has?*

Other (please state)

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

Do you or your family member qualify for disability support services through the Needs Assessment Agency?*

Would you like Care Matters to inform you about other workshops in your area?*

Would you like to share your contact details with the Waikato Enabling Good Lives Family Core Group? (Local community connecting)

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.

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Care Matters Workshop Registration Form

What is the purpose of this form?

Thank you