Zoom Registration Form - Care Matters

Care Matters Zoom Registration Form

Name

On-Line Zoom Meeting?

Preferred Time (please indicate)

Preferred date:

Address

E-Mail *

Phone/Mob

New to Care Matters?

How did you find out about us?

Other (please state)

What do you want to learn from attending?

In what capacity are you attending?

Other (please state)

What is your age group?

Other (please state)

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?

What is the purpose of this form?

To provide unidentifiable information to the Ministry of Health to create a clearer picture of who is accessing Care Matters face-to-face events. 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 Zoom Registration Form

Thank you