Title

Surname*

Given Name*

Home Address

Street 1*

Street 2

City*

Postcode*

Country*

Postal Address (please enter even if the same as your home address)

Street 1*

Street 2

City*

Postcode*

Country*

Telephone*

Fax

Mobile

Email*

Gender*

Date of birth

Name the area of the Performing Arts with which you are involved  (You may nominate more than one):*

Name the capacity in which you are involved (eg as performer, administrator, teacher or health carer) and state whether you are involved as an amateur or a professional: *

Amateur

Professional

Name any professional registrations and/or memberships you hold:*

It is the current policy of ASPAH, in order to establish from its outset the quality of its reputation, to vet all prospective members with respect to their character and bona fides. With this in mind we are asking all prospective members the following questions:

Have you at any time, in NSW or elsewhere, been convicted or made the subject of a criminal finding (other than in relation to an excluded offence)?*

NO

Are there any criminal proceedings pending against you in NSW or elsewhere in relation to a sex or violence offence?*

NO

Has your name been at any time, for any reason, suspended, erased or removed from any register or roll established or kept under any law in any country, State or Territory providing for the registration or certification of healthcare practitioners under a public authority, or been refused registration in any jurisdiction?*

NO