It is important that you write something in every box, even if it is just N/A, if it is not applicable to you. If you need help with this form, please get a support worker or friend/family member to help you or alternatively come in to MIX in person and a staff member will help you fill it out.

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

  • Personal Details

  • Date Format: MM slash DD slash YYYY
  • We 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 it
  • We 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 it
  • If you do not have an email address, please state "N/A"