FUSION WORKSHOP ENROLMENT FORM 2016/2017

Fusion is a series of ‘whole-of-community’ arts workshops, activities and events designed to increase social inclusion and engage people with disability.

To assist the artist in providing a workshop to suit participants’ needs it is essential to first complete the following enrolment form.

If you have any questions please contact our Project Officer Sarah Toohey on 08 9295 3991 or stoohey@mundaringartscentre.com.au >

PLEASE NOTE: Places are limited to 3 people per organisation. 

Participant Name *
Participant Name
Contact Person
Contact Person
If not participant
Contact Address *
Contact Address
The Fusion Project is part of the NDIS Hills Trial and priority is given to people living in the City of Swan and Shires of Mundaring and Kalamunda.
Will you require assistance to attend the workshop? *
Please note that all participants under the age of 10 must have a parent/guardian with them throughout the workshop.
If yes, Support Person/Parent/Guardian Name
If yes, Support Person/Parent/Guardian Name
Are you NDIS Registered? *
Do you have any support needs i.e. physical, social or sensory? *
Do you require assistance with mobility? *
Are you hearing or sight impaired? *
If yes, please select one of the following options
Do you have a medical requirement we should be aware of? *
Photography Consent
Do you consent for photographs of yourself to be used for promoting the Fusion Art Project? *
Do you consent for photographs of your artworks to be used for showcaing and promoting the Fusion Art Project? *