Retreat Expression of Interest

This field is hidden when viewing the form

Next Steps: Sync an Email Add-On

To get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.

Email Address*

Have you attended an overnight retreat or conference with Carer Kafe in the past 12 months?*

Please provide the year and brief details

First Name (Please make sure the name is the same on your ID - for check in at your accommodation)*

Last Name (Please make sure the name is the same on your ID - for check in at your accommodation)*

Mobile number*

Address*

Street Address City State Postcode

Age*

Gender*

I am a*

How many children do you currently provide home-based care for (excluding biological children)?*

How long have you been a carer for?*

Agency Name*

Agency Case Manager*

Agency Case Manager Email*

Do you identify as Aboriginal and/or Torres Strait Islander?*

Are any of the children or young people in your care identify as Aboriginal and/or Torres Strait Islander?*

Are you from a culturally diverse background?*

Are any of the children or young people in your care from a culturally diverse background?*

Do you have a disability?*

If relevant, does your carer need to attend the retreat with you?

Do any of the children in your care have a disability?*

Do you identify as LGBTIQ+?*

Do any of the children in your care identify as LGBTIQ+?*

Please advise if you have any specific accessibility requirements or anything else we need to be made aware of?

Do you have any dietary requirements?

Tell us in a few words how attending a Carer Kafe retreat would benefit the children in your care and yourself as a carer?*

What would you like to experience or see at the retreat? This could involve a session topic, activity or sharing a skill.*

If you do not secure a spot initially, what minimum amount of notice do you need in order to make arrangements to attend if we have a late cancellation?*

Can you please add a next of kin contact name, mobile and email address in the event of an emergency?*

How did you hear about this retreat?*

If other, please specify

CAPTCHA