The MISFIT Project Enrolment Form

PARTICIPANT DETAILS

Name*

First

Last

Phone

Email*

Address*

Street Address City State Post Code

Date of Birth*

day

month

year

PRIMARY CARER DETAILS

Primary Carer Name*

First

Last

Primary Carer Phone*

Primary Carer Email*

Primary Carer Address*

Street Address City State Post Code

EMERGENCY CONTACT DETAILS

Emergency Contact Name*

First

Last

Emergency Contact Phone*

Relationship to Participant*

MEDICAL INFORMATION

An emergency management plan must be submitted for any of the above conditions.

OTHER IMPORTANT INFORMATION

What would you like us to know about you to support you to engage in our programs *

In the event of an accident or illness, I authorise The MISFIT Project to obtain all necessary medical assistance and treatment for the participant. Treatments may include blood transfusions or anaesthetics. I agree to pay all associated medical expenses. *

Yes

Permission to reproduce photographical material in The MISFIT Project’s promotional materials

I give my permission for The MISFIT Project to use and reproduce photographic and video material for the purpose of: (cross out where permission is withheld)

The MISFIT Project newsletter
Posters, display board material, brochures, booklets and flyers.
Internet – The MISFIT Project Website and Facebook page.
The MISFIT Project linked sites and applications.
The MISFIT Project advertisements, articles in newspapers and other publications.

I give photo permission*

Yes

The MISFIT Project Enrolment Form

Enrol to become a MISFIT Project Member!

THE MISFIT PROJECT PARTICPANT ENROLMENT FORM

This form must be filled out before participating in any Misfit Project activities.