2022 Application Form - Participant (Queensland)

 
Thank you for your interest in Upbeat Arts Queensland. To apply to be a member of one of our programs, please complete 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 provide below.
 
Our programs are free to access and are delivered for the benefit of adults experiencing a mental illness, or anyone disadvantaged or marginalised. 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.
 

Important Information regarding Covid-19

 

Upbeat Arts is committed to continuing to provide our arts programs in Brisbane. With changing health directions, we may have to amend the way we deliver our face to face programs. Our members are kept up to date at all times. 

Please note any interaction with the general public poses an elevated risk of being exposed to COVID-19 and we cannot guarantee that you will not be exposed while attending our programs. You should seek your own medical advice prior to attending, and consider your individual situation.

 

A little about you

Name:

(leave no spaces)

Please select one from the list or add other

Tick any that apply and/or add 'other'

Choose from the drop down list

Tick any that apply and/or tick 'other' to include any other information you wish to share or think we should be aware of.

 

Program Selection

Choose one or more

 

For our records

Please tick which applies

 

Referrer details

If none, type N/A

If none, type N/A

Mobile required if wishing to receive weekly text reminders on behalf of client (see below)

This isn't a requirement, but an added service if this person wishes to be kept up to date with program activities.

Please tick which applies

 

Emergency Contact Details

Emergency Contact Name:

 

Thank You!

 
Please look out for your welcome email. You may need to check your spam/junk folder for an email from susan.gilmartin@upbeatarts.org.au. Please add this email to your safe sender list.
 
You will be sent important information about your weekly session via text or on the email address supplied here - please ensure you monitor incoming messages/emails the day prior to each session.
 

In submitting this form, you consent to Upbeat Arts liaising with your support team and/or emergency contact if required in relation to your involvement with Upbeat Arts.

You'll know we've received your application when you see a copy of this form in your inbox.

Please tick to verify that you are not a robot

 

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