Participant Intake Form V 1.2

Medication Declaration
Will Social Studio staff be required to administer/handle medication to/for the participant?*

YesNo
Name of Medication
Condition medication used for
Please give details of dosage, times and any other information

SOCIAL STUDIO PARTICIPANT INTAKE FORM

2. DISABILITY / MEDICAL CONDITIONS INCLUDING ANY DIAGNOSIS IF RELEVANT
Diagnosis
Is there a behaviour support plan in place?*

Yes - please attach belowNo
Please attach behaviour support plan if available

Or email to hello@socialstudio.com.au
Cancelof
Are there any challenges in the community that we should know about?
Triggers/signs to look out for;
Current strategies to deal with above triggers/signs;
If living independently will the participant require support in the event of a disaster or emergency in the local area?

YesNo
If you have answered yes to the above question please detail below

SOCIAL STUDIO PARTICIPANT INTAKE FORM

4. PARTICIPANT PREFERENCES
Participant Preferred Name
Religous Requirements
Cultural Requirements
Physical Assistance
Dietary Requirements
Allergies
Other Considerations
Interests Hobbies
Does the participant have a companion card?*

YesNo

SOCIAL STUDIO PARTICIPANT INTAKE FORM

5. Policies and acknowledgement
I understand that:
- These records are owned by this organisation.
- Information within these records will be shared with other staff within the organisation only whenstaff require the information to carry out their duties.
- I can ask to see records and receive a copy.
- Records are archived for a set period according to policy and procedure.
- I understand that all information obtained will be kept confidential.
Feedback & Complaints

Social Studio staff strive to provide exceptional services and we are continuously seeking ways to improve. You can contact our studio on 0459 955 300 or hello@socialstudio.com.au to provide confidential feedback and complaints in relation to services provided by Social Studio. Social Studio will follow up the complaint and respond within three (3) business days of receiving the complaint.

Cancellation Policy

Social Studio charges up to the NDIS price guide for services as outlined in your NDIS plan.

Social Studio do not charge GST on NDIS funded services in line with exemption guidelines for disability services.

In line with NDIS guidelines Social Studio will charge 100% of the scheduled service fee if service is cancelled within 1 clear business days. (to be reviewed in each case).
Photo Release and Waiver - Please advise

Yes I give consent to use my child's image in Social Studio marketing as per the below t and c's.No thanks
By choosing yes in the above question on this form I confirm that the person named in this participant intake form has agreed to the use, publication and reproduction by the Social Studio, its employees, officers, contractors or agents (“Social Studio”) of photographs (‘Photographs”) for the purposes in whole or in part, including on the Social Studio website or in publications for the Social Studio.

I, the parent/carer named in this participant intake form, grant the Social Studio the right to use the photograph/s and photographic negative/s (whether digital or film) on its websites and in publications, which may include, but is not limited to posters, newsletters and newspapers, catalogues, video and collages.

I also understand and grant the Social Studio the right to crop and/or collage the image/s with others. I understand the Social Studio may transmit the image/s in digital form over the Internet and that, while the Social Studio will exercise reasonable precautions to secure the image from distribution outside of the Social Studio, the image/s may inadvertently be transmitted to non- Social Studio Purposes.

I agree that the rights granted to the Social Studio under this release and waiver form are perpetual and I hereby waive any interest that I may have in the copyright of the Photograph now or at any future time. I acknowledge that I do not expect to receive payment or any other consideration in connection with taking, use or storage of the Photographs.

I acknowledge and agree that any use of the Photographs is, at the date of publication, made in good faith and is not intended to defame or offend myself/my child or bring my reputation into disrepute.

I acknowledge and understand that any photos or videos taken by support staff on their personal device, while on shift, will be deleted immediately after sending them to Social Studio administration.

I release the Social Studio, its employees, officers, contractors and agents from any and all claims and demands arising out of or in connection with the use of the said photographs/film, including but not limited to, any and all claims for invasion of privacy, defamation or financial compensation.
To the best of my knowledge the information provided in this form is true and correct and if I have selected Yes on the Photo release and waiver I agree to the above terms and conditions.
Agreed and Signed By Participant / Parent / Caregiver

Signature
Signature of Participant / Parent / Caregiver

Clear
Name of signatory*

First NameLast Name
Relationship to participant
Date*

DayMonthYear
Date
Should be Empty:

SOCIAL STUDIO PARTICIPANT INTAKE FORM V 1.2

Medication Declaration

SOCIAL STUDIO PARTICIPANT INTAKE FORM

SOCIAL STUDIO PARTICIPANT INTAKE FORM

To assist us to send accurate invoices please tell us below what Support Categories are in the participants NDIS Plan.

SOCIAL STUDIO PARTICIPANT INTAKE FORM

SOCIAL STUDIO PARTICIPANT INTAKE FORM