MIX

Join MIX

Welcome to MIX: Please enter your personal details. In order for you to get the most you can out of your time at MIX and for us to know how to best support your wellbeing and creativity, for you to attend regularly, we require this form to be completed. We have an obligation to report to the Ministry of Health, the Hutt Valley District Health Board, and the Ministry of Social Development about your attendance at MIX, but keep your information confidential (Privacy Act 1993). You are welcome to access and review your information at any time.

Step 1 of 5

Emergency and Clinical Contact Details
I understand that in an emergency MIX will contact my emergency contact person to explain the situation to them.
Emergency Contact*
Relationship to you*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email

If you do not have an email address, please state "N/A"
I do NOT want to be contacted at MIX by:
We will always check in with you before we make contact with your support people except in the case of a serious safety concern.
Name Relationship Name Relationship Name Relationship
Doctor/GP Name

Please provide at least one clinical contact
Organisation
Phone
I agree to MIX contacting my doctor/GP
I don't agree to MIX contacting my doctor/GP
Psychiatrist Name
Organisation
Phone
Consent
I agree to MIX contacting my psychiatrist
I don’t agree to MIX contacting my Psychiatrist
Clinical Care Co-ordinator Name
Organisation
Phone
Consent
I agree to MIX contacting my care coordinator
I don't agree to MIX contacting my care coordinator
Support Worker Name
Organisation
Phone
Consent
I agree to MIX contacting my support worker
I don't agree to MIX contacting my support worker

Travel Assistance
You may be eligible to receive financial assistance to travel to MIX through Work and Income.
Are you interested?*
- Yes
- No
We will check in with you to provide this letter of support once you have been attending MIX regularly.

Membership and Communication
Thank you for taking the time to fill this registration form out. You are now able to attend MIX. Once your registration has been processed, we will write a letter or an email to you, formally welcoming you to MIX.
I have read and understood the code of conduct in the Participant Orientation Booklet.
Would you like to be a MIX member?*
MIX members get to vote at the Annual General Meeting which means you get a say in how MIX is run. So you are aware, MIX shares stories and pictures via social media and newsletters. We will always contact you prior to doing this and request your consent. It is okay to say no.
- Yes
- No

Join MIX

Step 1 of 5

Personal Details

Emergency and Clinical Contact Details

Safety and Medical Details

Travel Assistance

Membership and Communication

Name	Relationship	Name	Relationship	Name	Relationship