Workshop Access Requirements Form

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Please complete all sections in this form BEFORE commencing any of our Silversmithing & Jewellery-making Workshops. The information provided will enable us to best support your individual needs in our workshop. Any information provided will be kept strictly confidential. If you need help completing this form, please contact us via email at erin@umbrella.org.au or phone at 07 4772 7109 (Monday to Friday 9am - 5pm).

Full name *

Are you aged 18+ ?

(this workshop is only suitable for adults)

Yes, I am 18+

Required

Do you identify as a person experiencing disability?
*

Yes

Required

Please tell us your primary diagnoses/disability (if applicable):

Do you have epilepsy?
*

Yes

Required

If yes, do you have an epilepsy management plan?

Yes

Do you have asthma?
*

Yes

Other:

Required

If yes, do you have an asthma management plan?

Yes

Do you have any issues with your vision?
*

Yes

Required

Describe any issues with your vision and/or any visual aids that you currently use:

Do you have any issues with your hearing?
*

Yes

Required

Describe any issues with your hearing and/or any hearing aids that you currently use:

What is your main method of mobility?
*

Please identify any (further) forms of assistance that you may need:

DECLARATION

I declare the facts stated in this form are true and correct to the best of my knowledge.

Required

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