PARTICIPANT APPLICATION FORM, Regional Queensland - Word on the Street

Thank you for your interest in Upbeat Arts Queensland. To apply to be a member of one of our online Regional Queensland creative writing programs, please complete this form. On receipt of your application, we'll check eligibility and availability of your program and be in touch with you via email.

Eligibility

Word on the Street Online members will need a referral from either Queensland Health, the agency they are working with or being supported by, or a medical professional to confirm a mental health diagnosis. You must reside within the region you are applying for. IE Wide Bay, Central Queensland, Sunshine Coast, Mackay or Darling Downs.
The referral body information is included in this form - no other forms are required.

A little about you

Name:

Regional Program Choice

For our records

Referrer Details

Emergency Contact Details

Name:

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