Register Register here to be involved with WAH’s programs Please contact Wild At Heart if you have any questions or access needs in filling out this form. You can download a MS Word version here.We’ll be in touch with you as soon as we receive your registration form. Name * First Name Last Name Preferred Pronouns (she/her, he/him, they/them ...) Email * Mobile * Country (###) ### #### Landline Country (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Are you your own legal guardian? Yes No Date of birth * MM DD YYYY Do you have an National Disability Insurance Scheme (NDIS) plan? * Yes No Your NDIS number Plan start date MM DD YYYY Plan finish date MM DD YYYY How is your plan managed? Plan Managed Self Managed NDIA Managed Plan Manager Email address for invoicing Support Coordinator First Name Last Name Support Coordinator Organisation Support Coordinator Email Support Coordinator Mobile Country (###) ### #### What music and arts making experience do you have? * My goals with music and community are: * I'd like to learn the following: * Do you identify with having a disability? * Yes No What type and level of support do you need to participate in Wild At Heart’s programs? * Do you have access or other issues we should know about to make your participation safe and enjoyable? Communication Medical Food allergies (anaphylactic) Behaviours of concern Guardian / Emergency Contact * First Name Last Name Relationship to participant * Mobile * Country (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Media Consent * I give my consent for my sound and image to be used by Wild At Heart to promote my artistic work and their programs. Yes No Is there anything else you'd like to tell us? Who has completed this form? * Thank you for registering with Wild At Heart. One of our team will be in touch shortly.
