clubCREATE:
New Member Form
First Name:
Last Name:
Home Phone:
Mobile Phone:
Email Address:
Do you identify as (select):
Male
Female
Other
Date of Birth (select Day, Month, Year):
1
2
3
4
5
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7
8
9
10
11
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31
Jan
Feb
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Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1985
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2011
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2014
2015
2016
2017
2018
2019
2020
2021
2022
Aboriginal
Torres Strait Islander
I identify with another Culture:
No
African
Chinese
Japanese
South-East Asian
Eastern European
Southern European
Western European
South American
Maori
Australian South Sea Islander
Other
Do you have a disability?
Yes
No
Prefer not to say
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:
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Country:
AUSTRALIA
NEW ZEALAND
Carer / Resi Worker (RW) FirstName:
Carer / Resi Worker (RW) LastName:
Carer / RW Phone:
Carer / RW Mobile:
Carer / RW Email:
Care Type:
Foster Care
Kinship Care
Residential Care
SAAP
Lead Tenant
Independent Living
Birth Family
Other
Case Worker FirstName:
Case Worker LastName:
Case Worker Agency:
Case Worker Phone:
I first entered care within the last 6 months
I heard about CREATE through:
Agency
Caseworker
CREATE Mate
Carer
Family Member
Friend
GYOW Leaving Care Kit
CREATE Event
CREATE Program
clubCREATE Magazine
CREATE Website
clubCREATE Website
CREATE Facebook
CREATE Hour 2014
Poster
Flyer/Brochure
Other
Please contact me by:
Email
Phone Home
Phone Mobile
Post
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.