Trying out MIX for the first time * I am interested in joining MIX for a day to see if it's the right fit for meHealth and Safety FormPlease help us to keep you safe by filling out a quick Health and Safety form. Name*Date of birth* Date Format: DD slash MM slash YYYY Email If you do not have an email address, please state "N/A"Phone Number*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 it.WINZ 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 it.Emergency Contact*Phone Number*Please Provide details on anything below that we should be aware of, and how we can best support you:Risk Factors e.g AllergiesIs 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?*For us to have better understanding of how to keep you and others safe, are there any risk factors we should be aware of?Required assistance with eating / drinking*If you require assistance with any of these activities, we will discuss this with you and you might be asked to bring a support worker along for when you are at MIX No Yes Required assistance with toileting* No Yes You’re welcome to get a feel of MIX for a week before completing a new registration by appointment with us. Please chat to a staff member about when we can go through the full registration with you.
