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Y Uplift Registration Form

Y NSW Uplift

1. Are you completing this registration yourself, or are you registering someone else for Uplift? *This question is required.

What is your full name?

What is your phone number?

What organisation are you from or what is your relation to this young person?

Participant details

2. Full Name *This question is required.

3. Phone number *This question is required.

4. Email address

5. Do you identify as any of the following? (optional)

6. Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Please list parent/guardian contact details

Full Name
Phone number

7. Gender *This question is required.

8. Which Uplift location are you registering for?

Please enter an 'other' value for this selection.

9. How did you find out about Uplift? *This question is required.

Please enter an 'other' value for this selection.

Please note that because you (or the person you are registering) is under 16 they will need a parent or guardian to sign them in for their first session.

What are you looking to get out of this program? *This question is required.

How would you rate your current mental health? *This question is required.

How would you rate your current physical fitness? *This question is required.