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Participant Enrolment Form
Participant Enrolment Form
Participant Enrolment Form
Participant Details
First Name
*
*
Last Name
*
*
Date of Birth
*
*
What is the gender of your participant?
*
She/her
He/Him
They/them
Let me type
I prefer not to say
Does the participant have Down syndrome
Does the participant have Down syndrome
No
Does the participant have Down syndrome
Yes
Country of Birth
*
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas, The
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin (Dahomey)
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Brunswick and Lüneburg
Bulgaria
Burkina Faso (Upper Volta)
Burma
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands, The
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo Free State, The
Costa Rica
Cote d’Ivoire (Ivory Coast)
Croatia
Cuba
Cyprus
Czechia
Czechoslovakia
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Holy See
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Namibia
Nauru
Nepal
Netherlands, The
New Zealand
Nicaragua
Niger
Nigeria
North Macedonia
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Republic of Korea (South Korea)
Republic of the Congo
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands, The
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Sweden
Switzerland
Syria
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates, The
United Kingdom, The
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Aboriginal or Torres Strait Islander origin?
Aboriginal or Torres Strait Islander origin?
No
Aboriginal or Torres Strait Islander origin?
Yes
Language/s spoken at home
*
Do you require an interpreter?
Do you require an interpreter?
No
Do you require an interpreter?
Yes
Are there any cultural specific needs you would like emotion21 to respect and be aware of?
*
Do you participate in other dance and/ or fitness?
Do you participate in other dance and/ or fitness?
No
Do you participate in other dance and/ or fitness?
Yes
Have you attended emotion21 programs before?
Have you attended emotion21 programs before?
No
Have you attended emotion21 programs before?
Yes
Street 1
*
*
Street 2
*
Street 3
*
Enter Suburb
*
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City
*
State/Province
*
ZIP/Postal Code
*
Country/Region
*
Participant MMM Region Code
*
Contact Details
Primary Parent or Support Person's First Name
*
*
Primary Parent or Support Person's Last Name
*
*
Primary Parent or Support Person's Home Phone
*
Caller Mobile
*
*
Primary Parent or Support Person's Email
*
Contact Type
*
Case Manager
Emergency Contact
Family/Primary Carer
GP
GP Practice
Guardian/Legal Representative
LAC
Nominee
Other/Informal Contact
Plan Manager
Planer
Portal Contact
Service Provider
Specialist
Supplier
Volunteer
Relationship to Participant
*
Carer
Partner/Spouse
Child
Sibling
Parent
Other Relative
Friend
Not Specified
Delegated Permission for related Participant
Delegated Permission for related Participant
No
Delegated Permission for related Participant
Yes
Emergency Contact
Do you wish for Secondary Parent or Support Person to receive email?
*
Emergency Contact First Name
*
Emergency Contact Last Name
*
Emergency Contact Mobile
*
*
Emergency Contact Home Phone
*
Emergency Contact Email
*
*
Please select the studio you are interested in attending:
Studio Locations
Please list any information that could assist us in teaching the participant
*
*
What you would like to achieve at emotion21?
*
What support from emotion21 do you need to achieve these goals?
*
*
