Group Program EOI A

Your First Name *

Your Last Name *

Your Email Address *

Your Mobile Number *

Participant Full Name *

Participant Date of Birth *

Participant Diagnosis *

Doe the participant have someone who is a representative, or who supports their communication with us? *

YesNo

Representative Full Name *

Participant/Representative Email *

Participant/Representative Mobile *

Suburb *

Which group is of interest? *

Group 1: The “ME” Project – Mums EditionGroup 2: The “ME” Project - Invisible Not Imaginary

Age Group

20 - 3030 - 4040 - 55

Do you/the participant have any specific mobility requirements or limitations? *

Do you/the participant have any specific sensory needs or accomodations? *

What sort of activities/events would you love to see included in this group? *

How would you prefer we get in contact with you? *

Phone CallText MessageEmailNone - Please contact my support coordinator/representative/the person who filled out this form