clubCREATE:
New Member Form
ClubCREATE Members Details
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
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
Please advise if you identify as -
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
Unsure
Care Type:
Foster Care
Kinship Care
Residential Care
SAAP
Lead Tenant
Independent Living
Birth Family
No longer Under an Order
Other
I first entered care within the last 6 months
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:
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
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:
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.