2023 Personal Information Form (Members)

2023 Personal Information Form - Members

Upbeat Arts is delighted that you are enjoying our programs. We now ask that you take ten minutes to complete this form. We ask you to complete this when you first join and then at the start of each new calendar year. This ensures our records are up to date and it serves as a reminder of our Upbeat Arts behaviours.

NEED HELP? If you need assistance completing this – please ask someone to help you or ask us. We’re very happy to help. We get it – forms can be a little daunting. We can help you next time you are in at your program.

A friendly reminder that it is your responsbility to keep Upbeat Arts updated with any changes to the information provided here. All personal information collected by Upbeat Arts Ltd is confidential. You may access your own personal records at any time. Upbeat Arts Ltd abides by the National Privacy Act.

Step 1 of 12

Member's email address(Required)

Choose an email address that you use regularly

Note: this email address may be used for forwarding information to you about your weekly program.

Member Personal Contact Information

First and last name of Upbeat Arts Member(Required)

First Last

Member's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Member's Phone Number(Required)

Mobile preferred

Note: this mobile number will be used for forwarding information to you about your weekly program.

Other phone (if you have one)

Age bracket (choose from the drop down list)(Required)

18 - 24

25 - 34

35 - 44

45 -54

55 - 64

65 +

Support Agency Details

Who has referred you to our program? Who is supporting you? (This might be Queensland Health, a non-government agency, a support / case worker or a medical professional - ie GP or psychologist etc)

Please provide the business/organisation name of the Qld Health Department, Non-Govt Agency or Doctor's Clinic/Surgery (please include one of these)(Required)

Contact Person at the above agency/department or clinic(Required)

Role of this person(Required)

Phone Contact (mobile if possible)(Required)

Email address (if available for support person)

Your Connection to Queensland Health

Our programs are funded by Queensland Health and for reporting purposes (de-identified) we'd like to understand your relationship to Queensland Health. Thank you for completing this information accurately.
YOU CAN SKIP THIS SECTION IF:
You indicated in Section 2 (Support Agency details) that you were referred to us directly by a Queensland Health service
OR If a Queensland Health service DID NOT refer you to your current non-govt support service

If a Queensland Health Service referred you to your current support agency, please choose which one

Queensland Health - Metro South

Queensland Health - Metro North

Queensland Health - other (please provide information below)

If other, please provide information on the Queensland Health Service you've been associated with

Emergency Contact

It's important we know who to call in the unlikely event of an emergency. The emergency contact you provide below or your support person provided above will be notified in case of emergency or if we are concerned for your well-being.

In completing this information, you agree to us contacting them if the situation arises.

Emergency Contact Name(Required)

First Last

Relationship to Member(Required)

Mobile Phone and/or home/work phone(Required)

Medical Information

Medical background (please indicate any of the following which apply)(Required)

Anxiety

PTSD

Bipolar

Intellectual disability

Depression

Dissociative identity disorder

Schizophrenia

Acquired brain injury

Addictions

Do you have any other pre-existing medical conditions we should be aware of(Required)

Yes

If you ticked or answered YES to any of the above, for our records and reporting (de-identified), please tell us a little more.

Please describe the condition you answered YES to (i.e. mental illness type) and what is done to manage it, or provide any information we should be aware of. (If no, enter n/a here)(Required)

Please list any current medications? Please include medication name, dosage, when and how you take it. Or upload below if you already have a written list

This information is not compulsory, however could be helpful in the unlikely event that we need to call an ambulance for you.

If you'd prefer to upload a copy of your medication list, you can do this here

Max. file size: 20 MB.

Please list any food / medication allergies? (If none, please type 'nil' here)(Required)

Personal Assistance

Please indicate any things on this list that may make you uncomfortable during your session/s with us(Required)

Loud or sudden noises

People behind me

Anxiety about performing (this is always your choice)

Stating my opinion

Starting conversations

Being touched

Worrying about making mistakes

Some song lyrics (if applicable to your program)

None of the above

Tick all that apply

What might help you to feel more settled(Required)

Deep breathing

Stepping out of the room for a while

Talking to someone

Some time-out alone / giving me some space

Massaging my hands

Running cold water over my hands

Moving / stretching

Activities on my phone

Having my concerns acknowledged

Reminding me of my helpful strategies

Not applicable to me

Tick all that apply

Do you need help with any of the following(Required)

Mobility

Reading

Writing

Hearing

Getting on and off stage (if applicable)

Nothing

Tick all that apply

Tell us a little about you

Any skills, qualifications or talents you'd like to share with us

Through your attendance at our programs, what would you like to achieve over the next twelve months. (tick any that apply)(Required)

New artistic skills (i.e. singing, acting, writing, song writing)

Increased social connectedness

Increased confidence

Increased self-esteem

Media Statement

From time to time Upbeat Arts Ltd trading as Upbeat Arts may commission or require that photographs, videos, and/or audio clips of any Upbeat Arts programs and their members be created ("Materials").
Upbeat Arts requests the right and consent to use the Materials in relation to the provision of its ongoing community programs and activities. The Materials may also be used in relation to the reasonable promotion and publicity of Upbeat Arts programs and activities and its fundraising and sponsorship activities. Such use many include, for example, use of the Materials in brochures, posters, flyers, website, press releases and newspaper and television news and current affairs programs.
By signing this form, I agree with Upbeat Arts and otherwise consent as follows:
1. That Upbeat Arts may use the Materials in the manner set out above.
2. That Upbeat Arts may use my First Name in connection with the above use.
3. That there will be no financial compensation for any such use (including any royalty payments).
4. That Upbeat Arts may authorise others to use the Materials provided that their use shall be consistent with the terms of this release and consent.
5. I agree that the photographs/video and/or audio remain the physical property of Upbeat Arts. Any further use of the Materials (eg in relation to any book, publication or television program on a commercial basis) shall be subject to a further agreement between Upbeat Arts and myself.

Media Release (choose one only)(Required)

I understand and agree to the terms and conditions of the media release above

OR I'm not sure. I need to speak to you about this.

Upbeat Arts Handbook

We're pleased to share with you our MEMBER HANDBOOK. Simply click on the link to access it. You'll also be provided with a hard copy of this Handbook for your information.
We encourage you to be familiar with the contents of your Handbook. If you need help to understand parts of it, please be sure to ask us.

Our Behaviours

'Our Behaviours' are guidelines on how to behave as a member of Upbeat Arts. In conjunction with the Member Handbook, please read thoroughly and think about what it means before you agree to abide by it.

By agreeing to the points within 'Our Behaviours', you agree to follow these guidelines and understand that we will speak with you if we feel you are not abiding by them. If required, we may issue a verbal or written warning, or in extreme situations, suspension or expulsion from your program may result.

We are respectful of each other’s rights and beliefs and always speak with kindness and an open heart.
We refrain from negative or hurtful comments. We are inclusive and accepting of everyone – knowing we are all equal.
If we have a concern about something to do with our program or another person, we’ll speak with the program leader directly.
We know that aggressive verbal or physical behaviour is not ok.

We’ll attend our program regularly and know that as long as we do the best we can, that’s ok. If we can’t make our program, we’ll do our best to let Upbeat Arts know.
We’ll be clean and sober at all Upbeat Arts programs, performances and events.
Having fun is key. We’ll learn, meet new people and enjoy the journey we’re on.

Be a role model by demonstrating a positive attitude, resilience, dedication and a willingness to learn and grow.
Be a good listener by showing a genuine interest in others and hearing their thoughts, feelings and experiences.

Our Behaviours (Please choose one)(Required)

I agree to respect myself and other members, staff and volunteers and will abide by the behaviours of Upbeat Arts

OR I'm not sure, I'd like to talk to someone further about this

THANK YOU - you did it!

We appreciate you taking the time to complete this information, which is a requirement for all members of our Upbeat Arts programs.
A reminder that we will ask you to complete this form annually. This is to ensure your information is updated regularly.
If you've any questions or comments about this form or anything to do with your Upbeat Arts program, please contact us at info.qld@upbeatarts.org.au
A copy of this completed form will be sent to you once you submit it. Please keep a copy for your records and remember to let us know if anything changes.