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Alphabet Soup Registration Form
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* Indicates required question
Legal Name
Your answer
Preferred Name
Your answer
Is this a name you only use in the group?
Yes
No
Date of Birth
*
MM
/
DD
/
YYYY
Age
*
Your answer
Postal Address
*
Your answer
I am:
Choose
An Aboriginal young person
A Torres Strait Islander young person
Other
What culture do you identify with?
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Phone Number
*
Your answer
Email Address
*
Your answer
How would you describe your identity?
Your answer
Do you have preferred pronouns? (e.g. he/she/they)
*
Your answer
Reason for joining? (e.g. to meet new people/questioning identity/social support/education/information etc.)
*
Your answer
What are some things you would like to know more about/be educated about?
Your answer
Are you interested in joining a closed Facebook group?
*
Choose
Yes
No
Do you consent for photographs of yourself to be shared on headspace Mildura's social media platforms? (Facebook/Instagram)
*
Choose
Yes
No
Only the closed Alphabet Soup Facebook group
Emergency contact details
(This does not have to be a family member, however emergency contact must be 18+)
Name & relationship to you
*
Your answer
Contact details
*
Your answer
Is your family/supportive person aware that you attend group?
*
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Yes
No
How did you hear about us?
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Your answer
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