Registration Form

Workshop Location *

Workshop date *

Name of person attending *

Date of Birth *

Gender *
Female
Male
Not specified

Indigenous Status *
ATSI
Non-ATSI

Language spoken at home *

Interpreter required *
Yes
No

Diagnosis: (if any) *

Any special access needs? (access, visual, hearing impairment) *

Are you registering as a group? *
Yes
No

How many people are registering in this group? *

Which organisation? *

Registering as an Individual? *
Yes
No

Name of Support worker *

Organisation *

Mobile *

Email Address *

Contact Person (person filling in form) *

Role/Relationship *

Organisation *

Referring Contact *

Phone *

Email *

Brief description of learning and communication needs of person *

If you have any questionsplease contact:
Email: admin@birdsandbees.com.au
Jodi Rodgers: 0422371331