Name
On-Line Zoom Meeting? Yes No
Preferred Time (please indicate) 11am 1pm 7pm
Preferred date:
Address
E-Mail *
Phone/Mob
New to Care Matters? Please select Yes No
How did you find out about us? Please select Care Matters/SAMS Parent to Parent Carers NZ Family/Friend School NASC
Other (please state)
What do you want to learn from attending?
In what capacity are you attending? Please Select Family Friend
Other (please state)
What is your age group? Please Select 20-29 30-39 40-49 50-59 60-69 Other
Other (please state)
What is your ethnicity? Please Select NZ European NZ Māori Samoan Tongan Niuean Chinese Indian
Other (please state)
Do you require any additional support to attend our workshop, e.g. do you have a visual impairment?
What is the main type of disability the person you live with/care for has? Please Select Autism Intellectual Physical Sensory Multiple Disabilities
Other (please state)
What is the age of the person being cared for?
Do you or your family member qualify for disability support services through the Needs Assessment Agency? Please Select Yes No
Would you like Care Matters to inform you about other workshops in your area? Please Select Yes No
What is the purpose of this form?
To provide unidentifiable information to the Ministry of Health to create a clearer picture of who is accessing Care Matters face-to-face events. The Ministry of Health acknowledges that under the Health Information Privacy Code (1994) all information will be received in the strictest confidence.
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