I.Power Registration Form

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you disability?: Name:

Name *

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Last

Date of Birth: *

Gender: *

Email: *

Phone Number: *

Are you currently attending school or any other courses? *

Emergency Contact Name: *

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Last

Emergency Contact Email: *

Emergency Contact Number: *

Do you identify with a disability?: *

Is there anything else you would like us to know about your accessibility needs?:

Tell us what you're most excited for the I.Power Program!:

Yes Disability Resource Centre
Email: ilead@yesdisability.org.nz
Phone: (09) 414 5360
PO Box 301 397, Albany