BYO Support Worker /therapist Form

1

Primary carer Name* This field is required.

First Name

Last Name

2

Primary care Email* This field is required.

example@example.com

3

Primary carer Phone Number* This field is required.

Please enter a valid phone number.

4

Accompanied Support Worker/therapist Name* This field is required.

First Name

Last Name

5

Accompanied Support Worker/therapist Phone Number* This field is required.

Please enter a valid phone number.

6

Child/ren name & NDIS number * This field is required.

7

I would like the activity fees to be ?* This field is required.

Added to the NDIS invoice as KM.

Paid by the support staff on the same day.

8

I allow the (above-mentioned) support worker to accompany & drive my child/ren to where the booked Wonder Kidz activity is* This field is required.I as ( Primary Carer)

YESNO

9

I allow the (above-mentioned) support worker to order/feed my child/ren and are aware of their allergies/medications at the booked Wonder Kidz activity is* This field is required.I as ( Primary Carer)

YESNO

10

I am aware that the (above-mentioned) support worker will be actively supervising my child/ren at the booked Wonder Kidz activity all the time * This field is required.I as ( Primary Carer)

YESNO

11

I am aware that the (above-mentioned) support worker when supervising my child/ren will communicate with the Team Leader if they need a break* This field is required.I as ( Primary Carer)

YESNO

12

I am aware that the required physical /sensory engagement may aggravate and cause behavioural escalation * This field is required.I as ( Primary Carer)

YESNO

13

I authorise the accompanied support worker to support my child/ren during sensory/physical/ behavioural escalation* This field is required.I as ( Primary Carer)

YESNO

14

I agree to pay the activity cost and authorise Wonder Kidz to claim it from my child`s plan if not paid during the booking.* This field is required.I as ( Primary Carer)

YESNO

15

I voluntarily choose to incur all the risks associated with engaging in the booked activity and understand that those risks may include: personal injury, property damage, and severe accidents for my child/ren or others. * This field is required.I as ( Primary Carer)

YESNO

16

I authorise Wonder Kidz to cancel/suspend /send home my Child/ren in the event of non-compliance with the safety rules or for reckless or inappropriate conduct.* This field is required.I as ( Primary Carer)

YESNO

17

I am aware that Wonder Kidz staff may take photos/videos of my child/ren during the booked activity. I will email ryounes@wonderkidz.net.au if I don't authorise that.* This field is required.I as ( Primary Carer)

YESNO

18

I confirm that the accompanying support worker does not work under Wonder Kidz or has read their policies and procedures. * This field is required.I as ( Primary Carer)

YESNO

19

I have read, understood, acknowledged and agree to the above terms and conditions in this waiver * This field is required.I as ( Primary Carer)

YESNO

20

Primary Carer Signature* This field is required.

Clear

21

Date* This field is required.

Date