Register your Interest

The information provided will be used to tailor the Shine Tribe Group Programme. Please return this with as much information as possible.

Name

First Name

Last Name

Date of Birth

YYYY

Phone

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Current School Status: Transitioning / Left

Support Person

Do you require a 1:1 Support Person during this programme:

Yes

Maybe

Tell us about your passions and interests:

What are your strengths?

Anything else you would like to share about yourself?

What brought you to Shine Tribe?

Emergency Contact 1

We require two contacts in case of emergency

Name

First Name

Last Name

Relationship

Phone

Emergency Contact 2

Name

First Name

Last Name

Relationship

Phone

Medical Information

Any Medical Conditions (if applicable) :

Diagnosed Conditions (if applicable) :

Any Allergies (if applicable):

Preferred Action in a Medical Event:

Behaviour Information

Any Challenging behaviour, stress/anxiety triggers:

Preferred Calming/De-escalation Strategies:

Thank you for providing your information. We’ll be in touch shortly with all the details.

Let’s Shine.