Expression of Interest
TMP-MBR-005_v7.0
1. Participant/ Member Details
Participant's Name
*
First Name
Last Name
Preferred Name
Gender
*
Please Select
Male
Female
Transgender
Intersex
Non-Binary
Other
Prefer not to say
Please add details
Date of Birth
*
-
Day
-
Month
Year
Date
Email
*
example@example.com
Participant Mobile Number (if applicable)
Address
*
Street Address
Street Address Line 2
City
State
Post Code
Are you completing this form for yourself or on behalf of another person?
Myself
Another person
Your name:
First Name
Last Name
Relationship to participant:
Parent
Guardian
Support Coordinator
Plan Manager
Other
Your Email
example@example.com
Your Phone Number
Should we contact you to discuss further?
Yes
No
Name
First Name
Last Name
Relationship to Participant
Phone Number
2. About You
Please provide details of any disability, mobility and/or medical conditions:
*
Do you have an NDIS Behaviour Management Plan?
Yes
No
Do you have a High Intensity Care Plan?
Yes
No
Please upload your NDIS Plan Goals:
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NDIS Plan Start Date
-
Day
-
Month
Year
Date
NDIS Plan End Date
-
Day
-
Month
Year
Date
How is your NDIS plan managed?
*
Please Select
Plan Managed
NDIA Managed
Self Managed
Please select the programs you are interested in
DAY PROGRAMS
9AM- 3PM Monday to Friday
Please tick the programs that you are interested in attending: (Please note all programs are subject to availability)
All Sports
Butterfly Bakers
Chippies Corner
Commando Outdoor Education
Community Connect
Drama Kings and Queens
Gone Fishin'
Farmability
Farmyard Cooking School
Fitness Fridays
Kiss My Art
Our Big Day Out
Rockability
Tech Connect
Social Butterflies (Fortnightly on Saturdays)
Please select which day/s you would like to attend Sunshine Butterflies
Monday
Tuesday
Wednesday
Thursday
Friday
AFTER HOURS & COMMUNITY SUPPORT
What type of after hours support are you looking for?
Supported Independent Living/ ILO
Weekend Support
Community/ In-home Support
Holiday Support
Respite
Please select which day/s you would like after hours and/ or community support:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Other Sessions and Therapies
Animal Enrichment Sessions
Exercise Physiology
Speech Therapy
Physio Therapy
Kinesiology
Personal Training
Massage Therapy
Comments
Was there anything else you wanted to tell us?
About Us
How did you hear about us?
Member
Word of Mouth
Internet/Website
Social Media
Advertising - Radio/TV/Newspaper/Digital
Other
Please verify that you are human
*
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