ASDESI Intake Form July 2022
Please complete the form below, which will be submitted to the Interchange team for review before approval.
Name of Child
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
NDIS Number (If Applicable) - Please note you do not need an NDIS plan to attend ASDESI Kids Klub
NDIS Plan Start Date
-
Day
-
Month
Year
Date
NDIS Plan End Date
-
Day
-
Month
Year
Date
Does your NDIS Plan have Social and Community Participation funding?
*
Yes
No
I don't have an NDIS Plan
Name of Primary Carer
*
First Name
Last Name
Relationship to Child
Parent
Grandparent
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
What days of the ASDESI Kids Klub would you like your child to attend?
*
Monday 4th July
Tuesday 5th July
Wednesday 6th July
Thursday 7th July
Friday 8th July
Monday 11th July
Tuesday 12th July
Wednesday 13th July
Thursday 14th July
Friday 15th July
Back
Next
What school does your child currently attend?
*
Grade/year
*
So that we can better understand your child's behaviour in a group setting, Has your child been suspended/excluded from school or another vacation care program? If yes, please provide details.
To help us better support your child, please tick all relevant boxes of behaviours your child has been known to display.
*
Impulsivity
Property Destruction
Absconding
Aggression - Physical
Aggression - Verbal
Self Harm
Oppositional Behaviour
Sexualised Behaviour - Self
Sexualised Behaviour - Others
Hiding
Stealing
Emotional Outburst
Sensory Needs
None
Other
Are there any specific triggers for these behaviours that we should be aware of?
How are these behaviours managed at home and is there anything we should know that will help us better support your child?
Does your child have any support plans? (behavior, epilepsy etc)
*
Yes
No
Upload any support plans
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Has your child received an official diagnosis?
*
Yes
No
If yes, please attach any relevant documentation e.g doctor's letter
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Does your child require 1:1 support from a support worker?
*
Yes
No
Child's Swimming Ability:
*
Non Swimmer
Beginner
Fair
Intermediate
Experienced
Back
Next
Doctor's Name
First Name
Last Name
Name of Surgery
Doctor's Phone Number
Please enter a valid phone number.
Medicare Number
*
Medicare Reference
*
Medicare Card Expiry
*
Does your child have any other health conditions?
*
Yes
No
If yes please attach any relevant documentation e.g doctor's letter or epilepsy management plan.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Does your child take any medication? Please note that all medication must be provided in a Webster-Pak.
*
Yes
No
Please give details on the name of the medication, condition it is used to treat, dosage and time of day to be taken.
Upload any relevant documentation for medication here:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Does your child have any allergies or dietary requirements?
*
Yes
No
Please list all allergies and dietary requirements
If you child suffers from Anaphylaxis, please attach their ASCIA plan here
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Name of Primary parent/carer with whom the child lives
*
Relationship to the child
*
Primary Phone Number
*
Secondary Phone Number
Does this person have permission to drop off/pick up the child from the ASDESI Program?
*
Yes
No
Name of Secondary parent/carer
*
Relationship to the child
*
Primary Phone Number
*
Secondary Phone Number
Does this person have permission to drop off/pick up the child from the ASDESI Program?
*
Yes
No
Is there anyone else who you authorise to drop off/pick up the child from the ASDESI Program? Please provide their full name and relationship to the child.
Upload Photo ID (Drivers Licence) for other authorised representative
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Are there any court orders or AVO's in place relating to this child? Please provide details.
I understand that from time to time Interchange Australia may take photos and/or videos of the children participating in activities. These photos and/or videos may be used in future marketing material for the ASDESI and 4K programs. If you require your child's face to be blurred in images please advise us of this.
*
I understand
Back
Next
Declaration: I understand that there are inherent risks of personal injury involved in the ASDESI Holiday Kids Klub, and I agree that my child participates in activities at his/her own risk. In the case of an emergency, I authorise Interchange Australia to arrange for my child to receive emergency medical treatment/s including ambulance transport that may be required. In the case of a cancellation with less than 2 business days notice, you will still be charged for the full price of the activity. Should we have to cancel or postpone an activity due to unforeseen circumstances, a replacement activity will be organised in it’s place. If the program is cancelled for the day, you will not be charged. Please note that all ASDESI fees must be paid PRIOR to the holiday program commencing. Any past outstanding invoices must also be paid before your booking will be confirmed. I have read and understand the information in this application. I declare that the information provided in this registration form is, to the best of my knowledge and belief, accurate and complete. I understand that this application is subject to approval by Interchange Australia.
*
I have read and agree to the above conditions
Signature
Clear
Back
Next
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform