Referral Form

Participant Section

To be filled out by workshop attendee

Title

Mr, Mrs, Miss, Ms etc.

Name *

First

Last

Phone

Date of Birth *

day/month/year

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Which group(s) would you like to try?

Workshop times can be found at theatrenemo.org/whats-on

Do you require:

I would like to borrow a tablet computer
Art Supplies
A Guitar (must be able to pick up from our studio)
A Ukulele

Theatre Nemo has been funded to supply art supplies and if required lend a tablet with internet data. Theatre Nemo staff are available to help you to use the tablet if needed. We are are also able to lend a guitar when neccesary.

Referring Agency

To be filled out by referrer, if you are self referring this can be left blank

Name

First

Last

Phone

Role

for instance O.T, CPN, CMHT, Social Worker

Does the person have a care plan and does this activity contribute towards it?

Please describe what outcomes are expected for the participant during their attendance at Theatre Nemo

Just to make sure you aren't a robot! *

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