clubCREATE: New Member Form
ClubCREATE Members Details
First Name:   Last Name:  
Home Phone: Mobile Phone:  
Email Address:   Do you identify as (select):    
Date of Birth (select Day, Month, Year):      
Please advise if you identify as -
I identify with another Culture:
Do you have a disability? Care Type:  
Please include any other information that may help us understand how we can best communicate and work with you. This can include information on any physical, sensory, intellectual or mental conditions or preferences you may have. (This can be physical, sensory, intellectual, or a mental illness.)
Postal Address
Street Address:   Suburb:  
Post Code:   State:  
Carer/ Resi Worker Details
Carer/ Resi Worker First Name: Carer/ Resi Worker Last Name:
Carer/ Resi Worker Phone: Carer/ Resi Worker Mobile:
Carer/ Resi Worker Email:
Case Worker Details
Case Worker First Name: Case Worker Last Name:
Case Worker Agency: Case Worker Phone:
Lastly, please tell us -
I heard about CREATE through:  
Please contact me by:  
Enter the code shown:

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.