Interested in joining MMAD?
Name of Participant
*
Participant First Name
Participant Last Name
Birth Date
*
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a month
Janeiro
Fevereiro
Março
Abril
Maio
Junho
Julho
Agosto
Setembro
Outubro
Novembro
Dezembro
Month
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Birth Date
*
 -
Day
 -
Month
Year
Date
Participant Mobile Number
*
Format: 0000 000 000.
Participant E-mail
*
example@example.com
Is the participant of Aboriginal and/or Torres Strait Islander origin?
*
Yes
No
MMAD Location
*
NSW
Participant Preferred Gender Pronoun:
*
He/Him
She/Her
They/Them
1.How happy are you with your life as a whole?
*
Very sad
0
1
2
3
4
5
6
7
8
9
Very happy
10
0 is Very sad, 10 is Very happy
2. How happy are you about the things you have? Like the money you have and the things you own?
*
Very sad
0
1
2
3
4
5
6
7
8
9
Very happy
10
0 is Very sad, 10 is Very happy
3. How happy are you with your health?
*
Very sad
0
1
2
3
4
5
6
7
8
9
Very happy
10
0 is Very sad, 10 is Very happy
4. How happy are you with the things you want to be good at?
*
Very sad
0
1
2
3
4
5
6
7
8
9
Very happy
10
0 is Very sad, 10 is Very happy
5. How happy are you about getting on with the people you know?
*
Very sad
0
1
2
3
4
5
6
7
8
9
Very happy
10
0 is Very sad, 10 is Very happy
6. How happy are you about how safe you feel?
*
Very sad
0
1
2
3
4
5
6
7
8
9
Very happy
10
0 is Very sad, 10 is Very happy
7.How happy are you about doing things away from your home?
*
Very sad
0
1
2
3
4
5
6
7
8
9
Very happy
10
0 is Very sad, 10 is Very happy
8.How happy are you about what may happen to you later in life?
*
Very sad
0
1
2
3
4
5
6
7
8
9
Very happy
10
0 is Very sad, 10 is Very happy
Referrer Name (if applicable)
Referrer First Name
Referrer Last Name
Permission to contact referrer
Yes
No
Referrer Email
example@example.com
Referrer Phone Number
EMERGENCY/MEDICAL INFORMATION
Parent 1/Guardian's Details
*
Parent 1/Guardian First Name
Parent 1/Guardian Last Name
Parent 1/Guardian Email
example@example.com
Parent 1/Guardian Phone Number
Parent 1/Guardian Phone Number
*
Format: (000) 000-0000.
Parent 2/Guardian's Details
*
Parent 2/Guardian First Name
Parent 2/Guardian Last Name
Parent 2/Guardian Email
example@example.com
Phone Number
*
Format: (000) 000-0000.
Parent 2/Guardian Phone Number
My insurance provider is
My insurance provider is
My medical provider is
My medical provider is
Reference number on medicare card
My child is taking the following medications
My child is taking the following medications
My child has the following allergies
My child has the following allergies
I would like to contribute towards MMAD's charitable programs for my child/young person:
Use my Creative Kids voucher
Use my NDIS plan
Creative Kids voucher number
I would like to make a donation
prev
next
( X )
AUD
Donation direct to MMAD
Credit Card/Debit Card
I AGREE TO THE FOLLOWING Parent/Guardian release is required if you are under 18 years of age.
*
AUDIO VISUAL AGREEMENT: Parent/Guardian release is required if you are under 18 years of age.
*
I authorise MMAD to publicly use audio visual content of me/my child to highlight and promote MMAD in any form of publication, production or presentation at their discretion. I also acknowledge that MMAD is not responsible for any release of public content by third parties.
*
Signature
*
Date of completion:
*
 -
Month
 -
Day
Year
Date
Submit
Should be Empty: