ACD Educate – ACD Connect Registration ACD Connect Registration form Date Please select the ACD Connect group you would like to attend:*Very Special Kids ( FULLY BOOKED)BendigoWarragul ( FULLY BOOKED)CardiniaCaseyDarebinManninghamMaroondahMonashMorelandSunburyWhittleseaWyndhamGeelongHorshamSaleSheppartonTrarralgonCobramSeymourMansfieldPersonal DetailsIndividual registration informationName* First Last Address* Street Address Address Line 2 Suburb State Post code PhoneMobileEmail* Enter Email Confirm Email Are you a current ACD member?*YesNoUnsureAre you Aboriginal or Torres Strait Islander?*YesNoDo you require an interpreter?*YesNoWhat is your preferred language?Do you have any dietary requirements?*YesNoThis information will assist us to cater for your needs.Please specify your dietary requirments:Your Child's detailsPlease provide some information about your child with a disability.Child's Name* First Last Child's age*Please enter a value between 0 and 25.Disability*Age child was diagnosed?*Do you have any accessibility requirements?*YesNoIf yes, please specify the accessibility requirementsDoes your child have a funding package?*NDISFlexible Support PackageIndividual Support PackageECISBetter StartHelping Children with Autism (HCWA)Continence PackageOtherPlease check as many boxes as necessary.If other funding package, please tell usHow did you hear about ACD Connect?*InternetEmailFlyerSupport GroupFamily/friendACDOtherIf other, please tell usSecurity CheckCommentsThis field is for validation purposes and should be left unchanged.