Carer Details

Caring Role

Relationship to Care Recipient

Care Recipients Name

Care Recipients Disability and/or Diagnosis

Care Recipients DOB

Provide a description of your Caring Role

Emergency Contact Name and Relationship

Emergency Contact Address

Does your Care Recipient receive NDIS, My Aged Care or QCSS?
YesNo

Do you have regular supports in place to support your Care Recipient and/or your caring role? If so, please provide a brief description

Any other information regarding your caring role, you'd like to share with Wellways, Carer Gateway and Carers Foundation Australia

Other Details

Are you registered with any service organization? If so, who?

Do you have any specific dietary requirements? If so, please list

Do you take daily medication? If so, please list

Please tick any of the following that are current conditions
AsthmaEpilepsyHeart ConditionSleep ApnoeaArthritisAllergiesDiabetesDepressionAnxietyOther?

Are there any other specific supports you require?

Carers foundation, like to tailor programs to meet interests as best as possible. Please list some of your interests

And/or indicate below your general areas of interest
Outdoor activitiesCreative activitiesMusicRelaxationSports / ExerciseMeditation/ MindfulnessYogaArtReadingHealth and Wellness

How would you best describe you current level of social interaction weekly?

Have you accessed counseling services during your time as a Carer?

On a scale of 1 - 5, how would you rate your current level of stress? (1 = low - 5 = high)

What support services do you currently access to manage stress?

What helps you manage your stress?

Do you have anyone that can care for the loved one you care for if you come on the retreat? If so who?

Do you require transport to get to the retreat?

Is there anything else you's like to share with us regarding your needs, support or assistance required in attending the retreat?

How did you hear about The Carers Foundation?

I agree and consent to registering with Wellways, Carer Gateway and understand
they will be funding my attendance of this retreat. I am aware that Wellways, Carer
Gateway will contact me after my attendance of the Carers Foundation Retreat.
Agree

Consent

WELLWAYS, CARER GATEWAY

1. Consent to the collection and use of personal information
I acknowledge that as part of my participation in Wellways programs, relevant personal information will be collected to assist Wellways to deliver services to me. This includes demographic data (e.g. age, gender, nationality) which is de- identified and provided to Wellways’ funding bodies or partner services for the purposes of improving service delivery and evaluation.

2. Consent to share information with other individuals and service providers - During our work with you, it is helpful for us to connect with your other supports (e.g. family, GP or other services) to provide safe and collaborative care. I consent to Wellways sharing information with other individuals or service providers relevant to my support. You can let us know about any specific individuals or service providers that you do not consent us to share information with here:

3. Consent to participate in quality audits Wellways undertakes regular quality audits to ensure we are operating within best practice standards and delivering a high quality of care. Auditors may access and review your file and/or contact you to discuss your experience with Wellways. If you are a NDIS participant, you will automatically be opted in unless you choose to opt out.
4. Consent to be contacted about research, marketing and advocacy Wellways advocates regularly for changes to policy in support of our participants and communities and conducts research to evaluate our services. As part of this work, we often seek the views and participation of people who access our services. You may also be invited to participate in community events and activities. I consent to being contacted by Wellways regarding research, marketing and advocacy opportunities.

Acknowledgment of Duty of Care and Handling of Information
There may be occasions when Wellways is required to share information with an individual or service without having prior consent. This would occur if we had concerns for your safety or the safety of others as part of our duty of care to you, or as required under law. I understand that Wellways has a duty of care and obligations under the law to share information when required.

Privacy and Storage of Your Personal Information
Your personal information will be treated in in accordance with the Privacy Act 1988 (Cth) and the privacy, health record, and data protection Acts of QLD, NSW, ACT, VIC, and TAS and managed in accordance with Wellways’ Privacy Policy. Information is stored for seven years from service exit. To request a copy of our Privacy Policy,
Minimum Data Set Reporting - Wellways is required by various government agencies and funders to report Minimum Data Set (MDS) information in order to facilitate the monitoring and evaluation of service provision and to plan future service improvements. This information can be provided beyond your participation with Wellways. All information will be de- identified (ie will not contain your name, or Medicare number for example).

THE CARERS FOUNDATION AUSTRALIA
I acknowledge that while the foundation, its foundation personnel, associated instructors and volunteers will make every reasonable effort to minimize exposure to known risks; all hazards and dangers associated with these activities cannot be foreseen or may be beyond the control of the foundation, its foundation personnel, volunteers and associated instructors. I agree to release from responsibility and waive any claims that may arise against the foundation or any foundation personnel relative to my attending the retreat and participating in the program and any activities. “The information that we collect from you on this form includes your personal information. Your personal information is protected by law, including by the Commonwealth Privacy Act. The client management system that we are using is an IT system called the ‘Data Exchange’. This system is hosted by the Australian Government Department of Social Services. Your personal information that is stored by the Department on the Data Exchange will only be disclosed to us for the purposes of managing your case. The Department de-identifies and aggregates data in the Data Exchange to produce information for policy development, grants program administration, and research and evaluation purposes. This includes producing reports for sharing with service providers. This information will not include information that identifies you, or information that can be used to re-identify you, in any way. You can find more information about the way the Department will manage your personal information in the Department’s APP privacy policy, which the Department has published on its website. This policy contains information about how you may access the personal information about you that is stored on the Data Exchange and seek correction of that information. This policy also includes information about how you may complain about a breach of the Australian Privacy Principles by the Department, and how the Department will deal with your complaint.”

As a parent/guardian I give my consent for him/her to participate in the Carers Foundation wellness program and agree to delegate my authority to the foundation personnel involved. Such foundation personnel may take whatever disciplinary action they deem necessary to ensure the safety, well-being and good conduct of the participants as a group, or individually in the above mentioned activity. I have read the program and agree to my son/daughter’s participation in all the activities listed in the program. I have received a copy of how the Carers Foundation cares for my privacy
(please see above)

AGREE to all the above

MEDIA RELEASE CONSENT
I agree that my engagement is subject to the conditions below:

Yes, I consent and agreeNo, I do not consent

The talent must at all times observe the directions of the representative of The Carers Foundation Australia (TCFA) and appear in such apparel and such setting and make such statements concerning TCFA as are agreed with TCFA.
The Talent consents to TCFA photographing and/or recording the Talents voice and or likeness whether by way of film, videotape, magnetic tape, digitally or otherwise. The talent consents to TCFA, its licensees, successors, and assigns, reproducing any photograph and /or recording of the Talents likeness, voice, any other sound effect made by the Talent and any written extraction made of any recording, in any media, whether by television broadcast, radio broadcast, print, online, multimedia broadcast to mobile telephone or otherwise. The Talent consents to TCFA, its licensees, successors and assigns using the Talents likeness for the purpose of promotion or advertising of the sale or trading in the photographs , recording and any copier made. The Talent and TCFA agree and acknowledge that all copyright in the photographs and recordings, including the right of reproduction wholly or in part, belongs to TCFA absolutely. The Talent agrees and acknowledge that the photograph and recordings can be used for an unlimited period of time anywhere throughout the world. The Talent agrees and acknowledges that they will not receive a fee for their service.