Champion Your Needs registration form

0508 236 236 | national@parent2parent.org.nz | www.parent2parent.org.nz

Region*

Please select your region

First Name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Phone number*

Email*

Gender*

Female Male Other

Do you care for anyone who receives disability support funding eg NASC, Respite, Home Support, Individualised funding.:*

Yes No

Please indicate the main disability of your child/family member*

Physical Intellectual Sensory Autism spectrum disorder

Other:

Are you happy for Parent to Parent to take photos for promotional purposes?*

Yes No

How did you find out about the Champion your Needs course?*

Your regional branch Parent to Parent eNews Parent to Parent website Care Matters Facebook and other Social Media Agency referral Newspapers or other print media

Other:

Are you intersted in learning more about volunteer opportunities with Parent to Parent?*

Yes No

The volunteer training option is not available at all courses.

If you are traveling we may be able to help. Please indicate below your requirements.

Accommodation night before and first night Accommodation first night only Car pooling opportunities

There may be costs associated.

Have you attended any previous training with Parent to Parent.*

Yes No

This includes the Care Matters Renew, Connect & Reflect Workshop

If yes, please specify

Please list any special dietary requirements

To keep our training accessible, please let us know if the following could be an issue for you.

Sight - reading standard text Hearing

Other: