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 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   1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 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
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
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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.