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Phantom of the Open Cinema

1. What is your full name? *This question is required.

2. What is your country of birth? *This question is required.

3. What is your year of birth? *This question is required.

4. What is your best contact number? *This question is required.

5. For how many years have you had caring responsibilities? *This question is required.

6. What are the needs of the person you are caring for? *This question is required.

Age related
Drugs and alcohol
Mental illness
Intellectual/cognitive disability
Physical disability
Other - please specify Please enter an 'other' value for this selection.

7. What would you love to be doing as a paid worker or volunteer?

8. What are some of the barriers preventing you from pursuing this ambition?

None
Carer commitments
Effect of income on entitlements
Confidence
Education/skill level
Carer's own health and well-being
Other - please specify Please enter an 'other' value for this selection.

9. What kind of support do you currently receive?

Carer Card (Vic Gov)
Companion Card
Carers Victoria members card
Carer allowance/payment
None of the above

10. Are you happy for your local neighbourhood house to contact you with information about supports available in your community?

*This question is required.

11. How did you find out about the event?

Please enter an 'other' value for this selection.

12. Which email address do you want the ticket forwarded to? This question requires a valid email address.

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