Adult's Form

Please make your term payment at the start of term. You can use a credit/debit card or cash payment. If you are experiencing any financial difficulties, please speak to MNH staff. Your term fee helps us to deliver our classes and programs. Thank you from MCH.

Name of Activity*Personal detailsfull name*phone*Email Address*home Address*genderBirthday*Country of birthlanguage spokenancestryAboriginalvisa type*household*disabilities and medicalDo you have a disability or any other needs we should know of to help you be part of the group/activity? If yes, please describe.Do you have any medical conditions or injuries that might inhibit you from participating in this class?to help us improveHow did you find out about the Mernda Neighbourhood House?Why did you choose to attend the Mernda Neighbourhood House?Emergency Contact Detailsfull name*phone*Relationship to Youprivacy statementsPermission for Mernda Neighbourhood House and Whittlesea Community Connections to enter my details into their data bases to be used for statistical purposes.*Permission for Mernda Neighbourhood House (MNH) and Whittlesea Community Connections (WCC) to use photos or videos of me in publications, on MNH and or WCC website and or social media to promote the group and work the organizations do.*I would like to be updated on Mernda Neighbourhood House programs and events and give permission to send information via email nominated on this form.*

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