Register Expression of Interest

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YES! I'm interested in being involved in Momentum'09!

1. CONTACT DETAILS

Name:

Organisation:

Address:

Suburb:

City:

State:

Zip:

Country:

Phone:

Mobile:

Email:

Website:

2. DELEGATE TYPE

I am interested in being a: (check one)

Contributing Delegate (please answer question 3)
Delegate only (please jump to question 4)

3. CONTRIBUTION

I am interested in contributing to the: (check as many as apply)

Keynote Speaker Programme
Artistic Programme
"Over the Edge" Programme
Market Place Learning
Policy Mini-Summit
Satellite event (self produced)

My biography and/or qualifications:

Details of my contribution(s):

4. ROLE

The following best describes me:

I identify as:

Disabled
Deaf
Mental Health survivor
Non-disabled
Other

5. TOPICS OF INTEREST

What specific topics would you like to see Momentum'09 address?

6. DEMOGRAPHIC INFORMATION

Gender

Ethnicity

Age

I understand that, in submitting this Expression of Interest, I am making no commitment to contributing to Momentum'09 and I may withdraw my Expression at any time. I also understand that Momentum'09 and its organisers make no commitment to act on my Expression of Interest.