Registration Form: CALD Senior Women’s Health Circle Program

Full name:

Date of Birth (DD/MM/YYYY):

Cultural/Ethnic Background:

Preferred Language(s):

Interpreter Required? Interpreter Required? Yes No

Country of Origin:

Year of Arrival in Australia (if applicable):

Phone Number:

Email Address :

Suburb:

Emergency Contact Name:

Relationship to You:

Emergency Contact Number:

To ensure the space is inclusive and welcoming, please share any support needs you may have: To ensure the space is inclusive and welcoming, please share any support needs you may have:Mobility assistanceVisual or hearing supportSupport worker or carer attendanceDietary needs or allergiesNoneOther- Please specificy below

Please specify any "other" Access Needs and Support here:

Please specify Dietary needs or allergies here:

Do you feel comfortable sharing any health issues or concerns relevant to participating in the program (e.g., chronic illness, mental health, pain, etc.)? (Optional – this helps us tailor support)

How can we help you feel safe, respected, and culturally affirmed in this program? (e.g., women-only spaces, prayer time, acknowledgment of cultural practices, etc.)

What would you like to gain from this Health Circle? Tick as many as are true about you. What would you like to gain from this Health Circle? Tick as many as are true about you. Social connection Gentle physical movement (e.g., walking, stretching) Mental wellness tools Culturally appropriate health information Creative or spiritual healing Sharing lived experiences

Note down here anything else you would like to gain from this Health Circle

Do you have any lived experience with family violence, trauma, displacement, or social isolation that you would like considered in how we support your participation? (Optional – you can speak with us privately if you prefer.) Do you have any lived experience with family violence, trauma, displacement, or social isolation that you would like considered in how we support your participation? (Optional – you can speak with us privately if you prefer.) Yes No I'd rather not say

Do you consent to participate in the CALD Senior Women’s Health Circle Program, with an understanding that your wellbeing is our priority and you can withdraw at any time? Do you consent to participate in the CALD Senior Women’s Health Circle Program, with an understanding that your wellbeing is our priority and you can withdraw at any time? Yes No

Would you like to receive updates or be invited to other community programs or healing circles hosted by AfriAus iLEAC? Would you like to receive updates or be invited to other community programs or healing circles hosted by AfriAus iLEAC? Yes No

Do you consent to non-identifying photos/videos being taken for community awareness or funding reports (optional)? Do you consent to non-identifying photos/videos being taken for community awareness or funding reports (optional)? Yes No

Date:

Signature (Please write your full name here to symbolize your signature/consent)

If you require assistance completing this form or would like to complete it in conversation, please contact us – we’re here to support you. 🌺 We honour your journey and welcome you in all your strength. This circle is your space – shaped by you, held by community.

Checklist Checklist I have read the information in this registration form/The information in this registration form has been read to me and I understand it. I have completed all the sections of this form. Any corrections have been initialled and dated by me (or assistant).