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 designed 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.

A little about you

Name:

Please choose from the drop down list

Tick any that apply and/or add 'other'

Choose from the drop down list

Program Selection

Choose one or more

For our records

Choose from the drop down list

Referrer details

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 you wish to be kept up to date with program activities.

Please choose from the drop down list

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.
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.
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.

Please tick to verify that you are not a robot

 

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