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 20% Personal DetailsFirst Name*Surname*Date of Birth* Date Format: MM slash DD slash YYYY NHI NumberWe need this number in order to fully register you at MIX. If you do not know it, please state "N/A" and ensure that you bring the number with you next time you visit MIX, and inform a staff member of itWINZ NumberWe need this number in order to fully register you at MIX. If you do not know it, please state "N/A" and ensure that you bring the number with you next time you visit MIX, and inform a staff member of itGender* Female Male Gender Diverse Prefer not to say Ethnicity*IwiPhone*Email If you do not have an email address, please state "N/A"Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Preferred method of contact*PhoneEmailWhat Kind of house do you live in?*Private ResidentialTemporary/Emergency AccommodationNo Fixed AddressRest HomeMental Health Supported accommodationHNZOtherHow did you hear about MIX?* Community Mental Health Friend GP whānau Hospital Other Please tell us your reason for wanting to attend MIX*Do you have a Wellbeing Plan, created by your doctor?* Yes No Emergency and Clinical Contact DetailsI 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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. NameRelationshipNameRelationshipNameRelationship Doctor/GP NamePlease provide at least one clinical contact OrganisationPhone I agree to MIX contacting my doctor/GP I don't agree to MIX contacting my doctor/GPPsychiatrist NameOrganisationPhoneConsent I agree to MIX contacting my psychiatrist I don’t agree to MIX contacting my PsychiatristClinical Care Co-ordinator NameOrganisationPhoneConsent I agree to MIX contacting my care coordinator I don't agree to MIX contacting my care coordinatorSupport Worker NameOrganisationPhoneConsent I agree to MIX contacting my support worker I don't agree to MIX contacting my support worker Safety and Medical Details For us to have better understanding of how to keep you and others safe, are there any risk factors we should be aware of?* No Yes, Provide Details below Please Provide Details of any Risk Factors: e.g. allergies, health conditions, seizures ...Is there anything about any health diagnosis (physical, intellectual, or mental health) we should be aware of that would be important for us to know to keep you safe?* No Yes, Provide details Are there any emotional or mental wellbeing risks we should be aware of and how can we best support you with these?* No Yes, Provide details Do you have any medical conditions we should be aware of?*NoneAddictionsEpilepsyAsthmaDiabetesHepatitisInsulin Dependent DiabetesOtherHow can we best look after you in a medical emergency with the above condition(s)?Are you regularly affected by seizures?* No Yes Please provide details on typical frequency, length, and how we can best support you if you have one at MIXAre you on any medications that we should be aware of that have bad side effects, or anything we should be aware of if you don’t take them?* No Yes, Provide details Do you have any dietary requirements or allergies we should be aware of?* No Yes, Provide details Do you require extra assistance with mobility in case of an emergency?* No Yes, Provide Details Do you require assistance with eating and/or drinking?* No Yes If yes, please have a support worker attend MIX with you at all times.Do you require assistance with toileting?* No Yes If yes, please have a support worker attend MIX with you at all times. We are unable to help with eating, drinking, or toileting needs at MIX. If you require assistance and you turn up without a support worker, we may have to ask you to leave. Travel AssistanceYou 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 CommunicationThank 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
