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Local Connect Adult

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PARENT DETAILS

I identify as Aboriginal and/or Torres Strait Islander origin :

*Username/Email :

*Password (minimum 6 characters) :

*Confirm Password :

Secondary Email (optional) :

* Parent First Name :

*Parent Last Name :

*Phone :

*Address :

*Suburb :

*Post Code :

*State :

*Region :

CHILD DETAILS

*Child First Name :

*Child Last Name :

*Child DOB (dd/mm/yyyy) :

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Please enter a valid date

*Is your child autistic or seeking diagnosis?

Food Allergies

*Childs Interests :

Does your child identify as Aboriginal and/or Torres Strait Islander origin :

If/when attending Yellow Ladybugs events, do you and your child give permission for their photo to be used for Yellow Ladybugs marketing purposes (eg website)? :

ADDITIONAL CHILD DETAILS (if applicable)

(not mandatory)

Child First Name :

Child Last Name :

Child DOB (dd/mm/yyyy) :

/ /

Please enter a valid date

Food Allergies :

Childs Interests :

Does your child identify as Aboriginal and/or Torres Strait Islander origin :

If/when attending Yellow Ladybugs events, do you and your child give permission for their photo to be used for Yellow Ladybugs marketing purposes (eg website)? :

ADDITIONAL CHILD DETAILS (if applicable)

(not mandatory)

Child First Name :

Child Last Name :

Child DOB (dd/mm/yyyy) :

/ /

Please enter a valid date :

Food Allergies :

Childs Interests :

Does your child identify as Aboriginal and/or Torres Strait Islander origin :

If/when attending Yellow Ladybugs events, do you and your child give permission for their photo to be used for Yellow Ladybugs marketing purposes (eg website)? :

YOUR DETAILS

*Reason for joining :

*Email :

*First Name :

*Last Name :

*State :

Please enter a value in all fields.

AUTISTIC ADULT DETAILS

I identify as Aboriginal and/or Torres Strait Islander origin :

*Username/Email :

*Password (minimum 6 characters) :

*Confirm Password :

Secondary Email (optional) :

*First Name :

*Last Name :

*Phone :

*Address :

*Suburb :

*Post Code :

*State :

*Region :

*Gender :

*Interests :

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Other Interests :

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