Adventure to Thrive Program

Please enable JavaScript in your browser to complete this form.
Adult Participation Information
or at Consent
Name
First
Last
Date of Birth
Gender
Mobile Number
Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Country
Consent
I consent to the collection and storage of my and my family’s personal information by Connected Self /AnglicareSA and that my personal information will be entered on to the DSS Data Exchange system from my first date of attendance. I understand that I can withdraw my consent at any time. Do you consent to being contacted by AnglicareSA or DSS at a later date to participate in follow-up, evaluation and/or research purposes?
Signature

Clear Signature
Would you like to receive regular information emails from Communities for Children on local events, activities, programs, and services relevant to children aged 0-12 and their families?
Email
How did you hear about this program/activity?
Emergency Contact Details
Name
Number
Relationship to child
Family Details
Are you of Aboriginal or Torres Strait Islander origin?
What is your Country of Birth if not Australia?
Date of First Arrival in Australia (if applicable)
What is the main language spoken at home if not English?
Do you identify as having any of the following disabilities?
Please explain 'other'
Are you eligible or receiving NDIS support?
Are you a Carer of a person with additional needs?
What is your Household Composition?
What is your Main Source of Income?

Communities for Children is funded by the Australian Government Department of
Social Services. Visit www.dss.gov.au for more information.