I.Power Registration Form

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Name: *

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Date of Birth: *

Gender: *

Email: *

Phone Number: *

Are you currently attending school or any other courses?: *

Emergency Contact Name: *

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Emergency Contact Email: *

Emergency Contact Number: *

What is your impairment?: (tick more than one option if neccessary) *

needs?: you're any

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

Register for a Showcase Day in your region.