Application Form Member

Application Form - Member

Application Form Member New

Company

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Thank you for your interest in Upbeat Arts.

• If you are NEW to Upbeat Arts and would like to join one of our programs – please complete this form.

• If you’re already attending our programs, or have previously been a member with Upbeat Arts, please contact us on 07 3073 2919 before completing this form.

• The email address for the new member of Upbeat Arts provided on this form must belong to the individual applying to join.

• Support/care team – should you either not have an email address for your client or there isn’t one, please contact us on 07 3073 2919 before completing this form.

On receipt of your application, we’ll check availability of your chosen program and be in touch with you via the email you have provided. You might need to check your junk/spam folder for your email – sometimes they will hide there.

Our programs are free to access and are primarily delivered for the benefit of adults experiencing a mental illness. Please include details of the person and organisation who has referred you (and/or supports you), ie Queensland Health; the Agency or Service you are working with or being supported by; or a medical professional.

This Upbeat Arts Application Form collects information to assist us to place you into one of our programs. All information will be treated confidentially and will not be used for any other purpose than what is stated in our Privacy Policy.

Tell us a little about you

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First Name(Required)

Last Name:(Required)

Preferred Pronouns

Suburb(Required)

Postcode:(Required)

Phone (mobile preferred)(Required)

When entering a phone number, please ensure you start entering from the far left hand side after the first bracket, so that all 10 numbers of the mobile number are shown. If adding a landline, please add the area code (ie 07) prior to the number.

Email(Required)

Enter Email Confirm Email

The EMAIL ADDRESS supplied here for the new member becomes the USER NAME for this member – so must be unique to the person registering to be a member. Therefore, it’s important to use a personal email address.
Support workers completing this form on behalf of a client: if you don’t know or don’t have an email address for your client, please make contact with us (07 3073 2919) before completing this form.

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Contact Type

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Status

Age Group(Required)

Gender(Required)

Do you identify with any of the following?

Aboriginal

Torres Strait Islands

Culturally or Linguistically Diverse

LGTBQI

None of These

Prefer Not to Say

Prefer not to say

Cultural Identity – Other

Other

If other, please provide details. You may share your ethnicity if you wish

Medical Information – (Please indicate any of the following which apply)*

Anxiety

Depression

PTSD

Dissociative Identity Disorder

Bipolar

Schizophrenia

Intellectual Disability

Acquired Brain Injury

Addictions

Autism

Eating Disorder

Medical Background – Other

Other

Please note: To ensure a calm and respectful environment for all involved in our choirs and writing groups, it’s important that members are able to manage their behaviour independently or with the support of an attending carer.

Please provide any other medical conditions and/or information you think we should be aware of:

Who are your existing supports?:(Required)
Please choose the answer that best describes where the majority of any support you receive comes from.

Food Allergies*

Gluten Free and Celiac
Gluten Free and Celiac

Dairy and Lactose Free
Dairy and Lactose Free

Nut Allergies
Nut Allergies

Seafood Allergies
Seafood Allergies

Food Allergies – None
None

Food Allergies – Other
Other

If you have any other food allergies, please provide details:

Which program/s would you like to register for?

Program Choice(Required)
Gold Coast Choir (Southport – Monday at 10am)
Creative Writing Online (Online – Monday at 2pm)
Creative Writing (Brisbane in Person or Online – Tuesday at 1pm)
North Brisbane Choir (North Brisbane – Wednesday at 10am)
Sunshine Coast Choir (Buderim – Thursday at 10am)
Brisbane Choir (South Brisbane – Friday at 10am)

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Brisbane Choir

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Gold Coast Choir

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Creative Writing (Brisbane in Person or Online)

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Creative Writing (Qld Residents)

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North Brisbane Choir

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Sunshine Coast Choir

For our records

How did you hear about Upbeat Arts? :(Required)

Are you an NDIS participant?(Required)

If a Queensland Health Service referred you to us or to your current support service, please choose which one:

Referrer details

What type of service referred you to Upbeat Arts:(Required)
Some examples:

• Agency might be Footprints, Open Minds, RFQ, or another similar service.

• Qld Health Service would be any of the public health system services.

• Medical Professional might be your GP or Psychologist.

What's the name of the Agency/Service Organisation or Medical Professional who supports you:(Required)
IE this might be Open Minds, RFQ, Queensland Health, your GP or Psychologist or an NDIS provider etc

Referrer Phone Number:(Required)
When entering a phone number, please ensure you start entering from the far left hand side, after the first bracket, so that all 10 numbers of the mobile number are shown. If adding a landline, please add the area code (ie 07) prior to the number.

Case/support worker name:(Required)
If you don’t have one, please type none

Case/support worker phone number:
When entering a phone number, please ensure you start entering from the far left hand side, after the first bracket, so that all 10 numbers of the mobile number are shown. If adding a landline, please add the area code (ie 07) prior to the number.

Case/support worker email address:

This isn’t a required field. Complete this only if you know the email address.

Emergency Contact Details

Emergency Contact Full Name(Required)

Emergency Contact Relationship:(Required)

Emergency Contact Phone Number:(Required)
When entering a phone number, please ensure you start entering from the far left hand side, so that all 10 numbers of the mobile number are shown. If adding a landline, please add the area code (ie 07) prior to the number.

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Year of Activity
25-26

CAPTCHA

We’ll be in touch to confirm your place. Look out for an email from us. If you don’t see it, check your junk/spam folder.

By submitting this form, you understand you’ll be added to our database for the purpose of sharing emails about your program/s.

By submitting this form, you understand we may contact the numbers you’ve shared, if we are concerned about your well-being whilst you are in attendance at one of our programs.

You’re now ready to hit the ‘SUBMIT’ button below.