Health declaration

Please fill out the following form.

First name

Last name

Email*

Date of birth

Day

Month

Year

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness or injury?

No

Yes

If you answered yes to any of the questions above, please supply additional information.

Initials*

I declare that the info I’ve provided is accurate and complete.

How satisfied were you with the event?

What was the best part of the event?

The content

The people

The food

The music

How relevant was it for you?

How convenient were the time & place?

Would you consider coming to future events?

Yes

No

Your email

Thanks for your feedback!

NIECH – Network of Inner Eastern Community Houses

ABN: 74 084 095 496
ACN: A0018668T

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