Community House

Enter Course Name *

Title

Mrs. Mr. Miss. Ms. Other (Please specify below)

(Other - Please Specify)

Name *

Address

Phone (Home) *

Phone (Mobile) *

Your email address

Enter this carefully so we can contact you

Date of Birth

Are there any medical issues we need to be aware of?

Does the participant or their caregiver have any access requirements? E.g. wheelchair

Are you happy to be on our database *

Yes No Already Registered

Name

Phone

Relationship to You

Gender

Female Male Other (Please specify below)

(Other - Please Specify)

What Language do you speak at home?

Is English your second language?

Are you Aboriginal or a Torres Strait Islander?

I allow photos to be taken as part of my class at Mt Evelyn Community House and Reading Room to be used on display boards, TV screens, website, Facebook, brochures, posters, newspaper articles and the annual report. *

Yes No

Course Booking Adult

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