Community House

Enter Course Name *

Title

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

(Other - Please Specify)

Name *

Address *

Phone (Home) *

Phone (Mobile) *

Your email address

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

Date of Birth

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 *

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 photographs/videos of my child to be taken as part of a class at Mt Evelyn Community House and Reading Room to be used on display boards, TV screens, website, Facebook, brochures, posters, newspaper articles or the annual report. *

Yes No

Course Booking Children

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