New to Care Matters? Please selectYesNo
How did you find out about us? Please selectCare Matters/SAMSParent to ParentCarers NZFamily/FriendSchoolNASC
Other (please state)
What do you want to learn from attending?
In what capacity are you attending? Please SelectFamilyFriend
What is your age group? Please Select20-2930-3940-4950-5960-69
What is your ethnicity? Please SelectNZ EuropeanNZ MāoriSamoanTonganNiueanChineseIndian
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? Please SelectAutismIntellectualPhysicalSensoryMultiple Disabilities
Other (please describe)
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? Please SelectYesNo
Would you like Care Matters to inform you about other workshops in your area? Please SelectYesNo
For catering purposes - do you have any dietary requirements (please state)?
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.
4 + 3 = ?Please prove that you are human by solving the equation *
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