Welcome to the Everyone Connects registration form!

** NOTE: Your answers will be saved only when you click on the final SUBMIT button. Please try to complete the registration process in one go. It should take you around 5-10 minutes to complete the form. 

Call 02 9912 5814 or email EveryoneConnects@at-aust.org if you need assistance.
Start Registration
 
Consent:
• I am attending an Everyone Connects event.

• I understand that my involvement is strictly confidential.

• I understand that any information collected during the project will be reported back to the Assistive Technology Australia (prev. Independent Living Centre NSW) and the Telstra Foundation, and may be published or presented. No information about me will be used in any way that is identifiable.

• I give consent to my participation in the project: Everyone Connects: Connecting People with Complex Communication Needs.

• I understand that by completing this registration form, I have indicated that I agree to the above.

 
What are the three main goals that you hope to achieve from attending Everyone Connects? *

 
Which event are you attending? *


 
Please select the date and location of the Communication Mini-Expo that you are attending: *


 
Are you a: *


 
If you are a family member or carer assisting the person in filling this form, please complete questions about the person with complex communication needs that you care for, even if the person with complex communication needs is not attending the mini-expo.

 
What's the first name of the person with complex communication needs? *

 
More information about {{answer_18460919}}:

 
{{answer_18460919}}'s surname: *

 
Suburb where {{answer_18460919}} lives: *

 
State where {{answer_18460919}} lives: *

 
Postcode where {{answer_18460919}} lives: *

 
{{answer_18460919}}'s phone: *

 
{{answer_18460919}} 's email: *

 
Age group of {{answer_18460919}}: *


 
Occupation of {{answer_18460919}}: *

 
Gender of {{answer_18460919}}: *


 
Language spoken at home: *


 
Aboriginal or Torres Strait Islands background: *


 
What is {{answer_18460919}}'s current living arrangement: *


 
What type of disability/diagnosis does {{answer_18460919}} have? *

(For example, cerebral palsy, autism, Down syndrome, stroke, brain injury, etc.)?
 
What areas does {{answer_18460919}} have difficulties with? [Tick all answers that apply] *


 
What communication needs does {{answer_18460919}} have? *


 
What is {{answer_18460919}}’s current level of understanding? *


 
Please describe the current methods {{answer_18460919}} uses to communicate: [Tick all answers that apply] *


 
What access methods does {{answer_18460919}} use for communication?
[Tick all answers that apply] *


 
Telecommunications:
Technology to help you communicate with people from a distance. For example: talk on the phone, send text messages, or make video calls.

 
What telecommunication device(s) does {{answer_18460919}} currently use or have access to? [You may choose more than one answer] *












 
How effective are the current telecommunication device(s) in meeting the needs of {{answer_18460919}}? Please rate. *

 
How confident is {{answer_18460919}} in using telecommunication device(s)? *

 
Please rate how {{answer_18460919}} finds operating their device(s): *

(For example, press the buttons, select options, read the screen, etc.)
1=Very difficult
10=Very easy










 
Does {{answer_18460919}} use social media? *

     
 
If yes, how does {{answer_18460919}} access social media?* *


 
If yes, how confident is {{answer_18460919}} in using social media?* *

1=Not at all
10=Very confident










 
Is {{answer_18460919}} attending the mini-expo? *

     
 
Please list any dietary requirements for {{answer_18460919}}: *

(Write "nil" or "none" if not applicable)
 
Please list any accessibility needs for {{answer_18460919}}: *

(Write "nil" or "none" if not applicable)
 
Would you like to add anything else?

 
Is a carer accompanying {{answer_18460919}}: *


 
Please complete this section about the family member/ carer:

 
Family Member/ Carer's Name: *

 
{{answer_18849259}}'s Surname: *

 
Suburb: *

 
State: *

 
Postcode: *

 
Phone: *

 
Email:

 
What is {{answer_18849259}}'s relationship to {{answer_18460919}}? *

 
Age group of {{answer_18849259}}: *


 
Occupation of {{answer_18849259}}: *

 
Gender of {{answer_18849259}}: *


 
Language spoken at home by {{answer_18849259}}: *


 
Aboriginal or Torres Strait Islands background: *


 
Please list any dietary requirements for {{answer_18849259}}: *

(Write "nil" or "none" if not applicable)
 
Please list any accessibility needs for {{answer_18849259}}: *

(Write "nil" or "none" if not applicable)
 
How confident is {{answer_18849259}} in using communication device(s)? *

 
How confident is {{answer_18849259}} in using social media? *

 
Would you like to add anything else?

 
Please fill in the following details:

 
Full Name: *

 
Suburb: *

 
State: *

 
Postcode: *

 
Mobile Phone: *

 
Age group: *


 
Occupation: *

 
Gender: *


 
Please list any dietary requirements below: *

(Write "nil" or "none" if not applicable)
 
Please list any accessibility needs:

(Write "nil" or "none" if not applicable)
 
Language spoken at home: *


 
Aboriginal or Torres Strait Islands background: *


 
Per year, how many clients/ people you work with have:

(Enter an estimate figure in the space provided. Enter "zero" in the space provided if none.)
 
Complex communication needs only: *

 
Vision needs only: *

 
Hearing needs only: *

 
A combination of the above: *

 
What type of disabilities do the people you work with have?
[Tick all answers that apply]
*


 
What methods of communication do the people you work with use?
[Tick all answers that apply] *


 
To access communication systems, what access methods have you had experience with? [Tick all answers that apply] *


 
A reminder to complete all the following in one go and click on SUBMIT at the end to register your answers. Otherwise your answers will not be saved. 

 
Telecommunications:
(Definition) Technology to help you communicate with people from a distance. For example: talk on the phone, send text messages, or make video calls. 

Examples include: 
> Smart phone (e.g. iPhone, Nokia Lumia)
> Tablet (e.g. iPad, Samsung Note)
> Speech Generating Device (e.g. Accent) 
> Computer
> Teletypewriter (TTY)
> Specialised telephone (e.g. big button phone, amplified speech)
> Specialised mobile phone (e.g. EasyCall, KISA)
> Regular telephone – Landline
> Regular mobile phone (basic features, no touch screen functions)

 
Have you recommended any of the listed communication or telecommunication options above to your clients/ people you work with? *


 
In general, how effective were the recommended telecommunication device(s) in meeting the needs of people with complex communication needs? Please rate. *

 
How confident are you in using these telecommunication device(s)? *

 
Would you like to add anything else?

 
How would you like to pay $35 for attending the Communication Mini-Expo? *


 
Direct Deposit Details:
Amount: $35
Bank: St George Bank
BSB: 112879
Account Number: 429540510
Description: ECA_[Surname]

Please attach a screenshot or copy of the direct deposit receipt. *

 
Invoice Details:

Please provide invoice details below. We will issue the invoice and email it to you upon submission of registration. Payment ($35) needs to be completed prior to event:
 
Company/ Organisation Name: *

 
Company/ Organisation Address: *

 
Name of person attending the event: *

Thank you for completing the Everyone Connects Registration Form. 
We are looking forward to meeting you soon!  

PLEASE CLICK BELOW TO SUBMIT ANSWERS. 
OTHERWISE YOUR ANSWERS WILL NOT BE SAVED.

{You will receive a confirmation email within 2-3 working days.} 
SUBMIT
Powered by Typeform
Powered by Typeform