Hub Enrolment Form

SECC Enrolment Form

Help us get to know you.
What would you like to register for? *

CPR for Babies & Toddlers Info Session for Parents Movement for Wellbeing Dance for Wellbeing Tai Chi Resume Writing Community Kitchen Maths or English Tutoring for High School Students Mothers' Circle The Community Pantry & Closet Sleep & Settle Info Session for Parents Gardening Group Toy Library A local playgroup Youth Picnics Resume Writing Assistance
Below are some demographic questions. This information will help us better understand your needs and how we can best address them. All the information you provide will be strictly confidential.
Personal Details
Name *

First Name Last Name
Birth Date *

Day Month Year
Gender *
Title *
Relationship status *
Address (if you do not want to disclose your full address, just provide us with your suburb, state and postcode) *

Street Address

Street Address Line 2

Suburb State

Postcode
No fixed address
Your Contact Details
Mobile number *
Home Phone

Area Code Phone Number
Email *
Emergency Contact Details
Name *
Mobile number (not yours) *
Relationship to you *
Demographic Details
Do you identify as Aboriginal or Torres Strait Islander? *
Country of birth *
Main language/s spoken at home *
How would you describe the makeup of your household? *

Single (person living alone) Sole parent with dependant(s) Couple Couple with dependant(s) Group of related adults Group of unrelated adults Homeless/ no household
Do you have a disability, impairment or condition that we need to be aware of? Tick all that apply. *

Intellectual/learning Psychiatric Sensory/speech Physical/diverse None
If you answered yes to any of the above, please specify:
Do you use any of the following mobility aids? *

Crutches Walking frame Walking stick Wheelchair No
Have you fallen in the last 6 months?

Yes No
Have you experienced any of the following in the past? *

Heart condition Respiratory condition Epilepsy Fainting or dizziness Head injuries of any kind Other physical or cognitive disabilities that might affect your ability to participate None
If you answered yes to any of the above, please specify:
Highest Level of Education/Qualification *
Employment Status *
Main Source of Income *
Income Frequency *
Approximate Gross Income (whole dollars only)
Please select your main reason(s) for accessing our services. (Please select the reasons that best describe your circumstances and needs. Speak to our staff if you’re not sure) *

Physical health Mental health, wellbeing and self-care Personal and family safety Financial resilience (e.g. difficulty finding money in emergencies) Employment Education and skills training Age-appropriate development (e.g. support with child's development) Community participation and networks (e.g. want to engage with the community more; feeling socially isolated) Family functioning (e.g. family conflict; needing support with family relationships) Material wellbeing and basic necessities (e.g. limited access to basic resources, food, clothes) Housing
How did you hear about us/ this program? *

Self Family member Friend SECC Website Facebook, In) Instagram TikTok GP referral or hospital referral Community services agency or community centre (e.g. JNC, The Deli) My Aged Care NDIS referral Educational institution (e.g. School, TAFE)
Participants consent (please read and tick to indicate you understand) *

I understand that there is an inherent risk in any exercise or activity, and that I participate in any activities and exercise at my own risk. I understand that if I do have any medical contraindication, then it is my responsibility to obtain clearance from my doctor before commencing any activities or groups provided by South Eastern Community Connect (Consent, changes, suspension, refusal or withdrawal of service is at the discretion of the CEO in compliance with SECC policy and procedures)
Would you like to keep informed about upcoming events and programs? *
Multimedia Consent
South Eastern Community Connect (SECC) may take photography, audio, and video recordings throughout the duration of its programs and activities for multimedia content production which is typically used in organisational promotion and marketing in a range of platforms and mediums. Do you provide multimedia consent?
*

No, I do not provide multimedia consent. Yes, I, as named above, consent to South Eastern Community connect and its agents (including without limitation, any photographer, interviewer, creative agency or media organisation) recording images of me during SECC events, programs and activities for promotional purposes. I consent to these images being used and disclosed to any person or organisation approved by South Eastern Community Connect, including without limitation, by publishing them as part of a book, poster, brochure or report, newspaper advertisement or article television advertisement or program, radio advertisement or program and including on the world wide web or any other social media. I agree that South Eastern Community Connect and its agents may edit the images prior to publication, as they consider appropriate, without first consulting me.
Privacy and Confidentiality Policy
SECC has a strict policy around issues of privacy and confidentiality. All files are securely maintained.Your name and personal details will not be given to any person or agency outside of the Centre without your informed and voluntary consent. Exceptions to this agreement involve:
- Where a child or young person under the age of 16 years is at risk of significant harm from abuse or neglect (e.g. a child or young person witnessing incidents of Domestic Violence)
- Where there is a serious and imminent threat to life and health of any person, including the person seeking a service (e.g. a person is at risk of hurting themselves or harming others)
- Where a person discloses information that would substantially assist in the prosecution of any offence punishable by 5 or moreyears imprisonment
- Where a worker is required to provide documents (e.g. a person's file) or give evidence under subpoena
If you have any questions, please ask a staff member-all SECC staff can describe these exceptions in more detail.
Data Collection Consent
The information you provide on this form includes your personal information. Your personal information is protected by law, including by the Commonwealth Privacy Act.

We are using an IT system called the ‘Data Exchange’ to store your information. This system is hosted by the Australian Government Department of Social Services (DSS). The personal information that is stored on the Data Exchange is only disclosed to us for the purpose of managing your case.

You do not have to consent to sharing your personal information with DSS. If you do not consent to us sharing your personal information, it will not affect the services you receive. If you do consent to sharing your personal information with DSS, you can ask for this information to be removed at any time.

DSS de-identifies your data. This means they remove information that identifies you or that could be used to re-identify you (e.g. your name).

DSS combine your data with other clients’ data in the Data Exchange to identify trends at the program level. This information is used to develop policy, administer grants programs, and conduct research and evaluations.

DSS may use this data to produce reports. These reports may be shared with other organisations. The data in these reports is de-identified.

You can find more information about how DSS will manage your personal information in the DSS privacy policy on their website: https://www.dss.gov.au/privacy-policy. This policy explains:
• how to access the personal information that is stored about you on the Data Exchange
• how you can ask for this information to be changed or removed.
• the circumstances in which DSS may disclose personal information to overseas recipients
• how to complain about a breach of the Australian Privacy Principles by DSS, and how DSS will deal with your complaint.
I consent for my personal information to be stored in the Data Exchange *

Yes No
I consent to participate in follow up research, surveys or evaluation *

Yes No
Follow SECC on Facebook and Instagram and keep informed.
SECC collects basic program statistics. The collection is for funding and reporting purposes. The collection never identifies individuals. The collection allows us to monitor service usage patterns across the years. It also allows us to report to our Board and the bodies that provide us with funding with service provision. At no stage is any identifying data provided to either the Board of SECC or to funding bodies. If you choose to not have this particular information passed on you are able to inform the worker. You will still be able to receive services from SECC. Do you consent to the collection of statistics for the purposes stated above on the condition that any collection will not identify you personally?
Signature

Clear
Should be Empty:

SECC Enrolment Form

Personal Details

Your Contact Details

Emergency Contact Details

Demographic Details

Multimedia Consent

Privacy and Confidentiality Policy

Data Collection Consent