Online OPAP Intake Form – East Creek Community Centre

Name *

First

Last

Gender *

Male
Female
Non-Binary

Date of Birth *

Background *

Aboriginal / Indigenous
Torres Strait Islander
Culturally or Linguistically Diverse
None of the Above

Residential Address *

Postal Address *

Phone Number *

Alternative Number (optional)

Email Address *

Preferred Method of Contact *

Call
Text / SMS
Email

Emergency Contact Name *

Emergency Contact Number *

Emergency Contact Email Address *

Would you like to receive any East Creek Newsletters?

Yes – Centre Newsletter
Yes – OPAP Newsletter
Yes – Both Newsletters
No

Do you have any health issues you would like us to be aware of? Please list. *

Do you have any mobility issues you would like us to be aware of? Please list. *

Do you have any dietary requirements you would like us to be aware of? Please list. *

Do you require any assistance with transport? *

Yes
No

How did you hear about East Creek? (optional)

Consent *

By entering your name in this field (digital signature), you are consenting to East Creek Community Centre providing your services related to the Older Persons Action Program, and for information to be collected, accessed, used, stored and distributed in line with our Information Management, Privacy and Confidentiality Policies. You also consent that your information may be de-identified and used as for statistical purposes for reporting to any of East Creek’s funding bodies. Should you not agree with any of the above statements or require clarification, please do not complete this form and contact a member of staff on (07) 4639 2755 or 0468 792 755.