STA Referral Form

2. Participant Info
PARTICIPANT INFO

Please Answer All Questions To Proceed
Participant full name*

First NameLast Name
Participant email
Gender/pronoun*
Participant date of birth*

DayMonthYear
Participant mobile number
Mobile
Participant address*

Street Address 1

CityState / Province

Postal / Zip Code
Do you give consent to travel in a vehicle with our logo and advertising material displayed?*

YesNo
Are you an existing participant with Mighty Mentors?*

YesNo
Do you have a companion card?*

YesNo
Companion card number?
Do you have a concession card?*

YesNo
Concession card number?

5. Support Needs
SUPPORT NEEDS

Please Answer All Questions To Proceed
Please list your disability and any support needs*

0/45
Are you a wheelchair user?*

YesNo
Do you have a behaviour support plan in place? if yes, please provide more details*

0/45
Do you have any dietary requirements or allergies?*

0/45
Do you require prompting or administering of your medication?*

0/45

6. Preferences + Dates
PREFERENCE + DATES

Please Answer All Questions To Proceed
Please advise any mentor preferences *

0/45
Preferred dates of STA*
Areas you'd like respite?*
Consent to MM using images/videos on our website & social media?*

YesNo
Would you like photos taken of yourself during your STA with us, so that we can create a digital photo album of all your amazing memories during your stay?*

YesNo
How did you hear about us?*

Social MediaWord of MouthSupport CoordinatorOther

STA REFERRAL