VicHealth Smartphone Stories - Registration Form

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To register for a VicHealth Smartphone Stories workshop, please fill out the information on all pages in this form, and submit. Personal information collected is protected by The Privacy Act 1988. Statistical data or responses collected may be provided to funding partners, but all other information shall be kept confidential.

Further details about venue and what to bring will be sent in a confirmation email of your place.

Please note places are limited, and registrations over the recommended class size may be added to a waitlist.

Email *

Registering for which upcoming workshop? *

Your Name *

Your Address: *

These workshops are open to all Victorian residents.

Your Postcode (e.g. 3000) *

This information is a VicHealth statistical requirement

Mobile Phone contact: *

Date of Birth (optional, if over 18 years of age):

YYYY

Emergency contact name:

Emergency Email contact: *

Emergency contact phone:

Please feel free to let us know of any personal identifiers (optional, check any that apply):

Gender - Male

Gender - Female

Gender - Other

Aboriginal or Torres Strait Islander

Culturally & Linguistically Diverse

LGBTQI

Disability (mental)

Disability (physical)

Mature age (self defined)

How did you find out about this program?

You will use your phone as a filmmaking tool within the workshop. So we can plan, please let us know what phone model do you use (e.g. iPhone, Samsung)?

Current occupation or student year level:

Do you have any special needs, dietary/allergy or medical requirements? Do you need assistance with transportation to the workshop?

* please note catering is not available at all locations, but a lunch break is provided. Tea & coffee is available at all workshops.

Do you have a current Health Care Card (HCC)? *

This information is a VicHealth statistical requirement, but is not necessary to participate in the workshop.

Yes

I have read and agree with the Terms and Conditions for this program:

Please open the T&C's link at the top of this page. If under 18 years of age, your parent or guardian listed as your emergency contact needs to have read and agreed to these T&C's before submitting this form.

Yes, I agree

No, please contact me to discuss

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What we ask of participants... *

I acknowledge that this workshop is run over a number of sessions and commit to attending all sessions

All participants will be given skills and support to create two short films as part of this program

Required

A copy of your responses will be emailed to the address you provided.

Submit

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