ER Registration Update Form - (Change in Client Details)

(Insert Site Name) Community Support Services.

ER “Registration Update” Form - (Change in Client Details)

Only record “new or changed” client informationon this form.

Remainder of form can remain blank.

REGISTRATION UPDATE - PERSONAL DETAILS:

First name: ______Surname: ______

Address: ______

Suburb: ______Postcode:______

Date of birth: ______Phone:______Mobile: ______

Email Address: ______

ATSI: Neither Aboriginal Torres Strait Islander Both

Country of Birth: ______Year of Arrival in Australia: ______

Residency Status:______Ethnicity: ______

Main Language Spoken at Home: ______

Privacy Consent - Important

By signing this document and accessing assistance from The Salvation Army, I acknowledge

• that I have been provided with a copy of The Salvation Army Privacy Notice;
• that I have read and understood the Privacy Notice and freely agree to provide the sensitive information referred to and/or contained in this document to The Salvation Army;
• that the information I have provided to The Salvation Army is current and I consent to the disclosure of this information to the types of organisations or individuals identified in the Privacy Notice;
• that I undertake to notify The Salvation Army as soon as practicable if this information is no longer current or if my consent for the collection of this information is withdrawn;
• that until such time that I notify The Salvation Army that my consent is withdrawn, I agree that The Salvation Army will be entitled to presume that this consent is current and informed.

Signature of Client ______Print Name ______Date ______

REGISTRATION UPDATE: PERSONAL DETAILS (Cont’d):

Dependents residing at your current address:

First name/Surname Sex DOB Relationship Country of Birth

______M / F ______

______M / F ______

______M / F ______

______M / F ______

______M / F ______

REGISTRATION UPDATE: Demographic and Other Information:

Territorial Social Program Department (AUS) – Client Registration Update Form Version 1.16 - March, 2016 Page 1