Ādaptive Arts Registration Form

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Name *

First

Last

Date of Birth *

Main Contact Number *

Street Address *

Suburb *

Email Address *

Wednesday Session

Friday Session

(LUNCH – Social Time between Morning and Afternoon groups – bring your own food and drink)

Nationality *

Ethnicity *

Gender *

Permanent Resident *

Residential Care *

Type of Disability *

Do you have any medication kept on you? *

What is it and kept where?

Allergy Details

Full Gender /

Emergency Contact #1 Full Name *

First

Last

Emergency Contact #1 Relationship / Phone Number *

Emergency Contact #2 Full Name *

First

Last

Emergency Contact #2 Relationship / Phone Number *

Photo Permission *

Payment can be done monthly via AP, or IF, CS WINZ. Please let us know what process you prefer.

If you have any questions please write here Or Contact us on Phone: 0210 800 7199 / Email: info@bans.org.nz