clubCREATE: New Member Form
First Name:   Last Name:  
Home Phone:   Mobile Phone:
Email Address:   Do you identify as (select):    
Date of Birth (select Day, Month, Year):      
I identify with another Culture:
Do you have a disability? If you would like to add more information, please write in the box below. This can help us understand how we can best communicate and work with you.
(This can be physical, sensory, intellectual, or a mental illness.)

Member's Contact Details
Postal Address:   Suburb:  
PostCode:   State:  
Country:

Carer / Resi Worker (RW) FirstName: Carer / Resi Worker (RW) LastName:
Carer / RW Phone: Carer / RW Mobile:
Carer / RW Email: Care Type:  

Case Worker FirstName: Case Worker LastName:
Case Worker Agency: Case Worker Phone:
I heard about CREATE through:  

(If Hard Copy is selected you need to tell us if you change your address.)  
Please contact me by:  
CREATE Foundation Privacy Disclaimer
This information will be used so CREATE Foundation can write to you or ring you to invite you to events and/or ask you to participate in research. We ask for your carer's name so we know who is responsible for your day-to-day care and so we can use their name if they answer the phone. Your carer's name is not essential. It's a good idea to let your carer know that you are joining clubCREATE. The clubCREATE database is password protected. Information security is guided by our Privacy Management Policy. No child or young person's record will be made available to anyone outside of the organisation without a duty to provide it. Within the organisation a child or young person's personal information is only accessible to those who need it to carry out their functions and obligations.