STARS Enrolment Form

Please note that completing this enrolment form does not guarantee your space in a STARS Group. Your enrolment will be confirmed by the Client Manager, who will provide you with further details once your enrolment has been processed.

Participant Information

Persons name *

First name

Last name

Nick name

Person or Household Address *

Address line 1

Address line 2

Address line 3

Address line 4

Town/Suburb

City

Postcode/Zip

Email address *

Home phone

Cell phone *

Date of Birth *

Iwi

Ethnicity (for funding/reporting purposes) *

Gender (for funding/reporting purposes) *

Pronouns *

Parent/Caregiver Name *

Parent/caregiver email *

Parent/caregiver phone number *

Preferred contact method

Diagnosis (if applicable)

Conditions that therapist needs to be aware of

Means of communication *

What is the primary method of movement (e.g., walking, wheelchair, use of aids)? *

Languages used at home

Previous Dance or Arts Therapy?

Where did you hear about DTNZ?

About Me

My likes, hobbies, favourite music, favourite things etc.

My dislikes

What helps me stay calm?

What helps me regulate?

Are there any triggers that may cause distress, ie. flashing lights, sudden loud noise, etc?

Do I sometimes show challenging behaviour in group settings?

Am I able to participate independently in a group setting, engaging safely and collaboratively with others?

Have I previously participated in a group setting, ie. Star Jam?

Consent for Photography and Use of Images

Capturing photos and videos during sessions is an important part of our work. These images help us share the positive impact of our programmes with our funders, assist in improving our services, and support our marketing efforts to reach more families in need. Your consent allows us to use these visuals to tell the story of our work and its benefits.

For funding purposes only (not shared publicly)

For marketing ie. flyers, social media, website

Trial Period and Group Placement Disclaimer

I, the parent/caregiver, understand that the first term of attendance is considered a trial period. If it is determined that the participant may be more suited for individual sessions, DTNZ reserves the right to discuss alternate options *