FHC Superheroes

School Holiday Program Registration Form

Facilitated by Felicity Holistic Care.

First Name*
Last Name*
Address*

Street Address

Street Address Line 2

SuburbState

Post code
Birth Date*

DayMonthYear
We offer a pick up and drop off service in the Wyndham region.
Pick up / Drop off required*

YesNo
Please indicate the pick up/drop off location

Companion Card Holder*

YesNo
If you would like to know how to get a companion card tick here

YesNo
NOTE:
- Please bring your Companion Card on the day.
- Also, Please upload Companion Card as part of this application

SCHEDULED ACTIVITIES - Please select the activities you would like to participate in.*

Tuesday 7th April You Yang Park (Free)Wednesday 8th April Masterchef @ Centre (Free)Thursday 9th April Flipout @Derrimut $20Friday 10th April Movie-$17(Altona)/ Arts & Crafts at centre-Free

SCHEDULED ACTIVITIES - Please select the activities you would like to participate in.*

Monday 13th April Sovereign Hills - Ballarat $33Tuesday 14th April Aquatic Centre in Melton (Swimming) $10Wednesday 15th April Bowling and Mini Golf @ Wyncity pointCook- $21Thursday 16th April Pick Your Own Fruit- Paynes Orchards- Bacchus Marsh-$5Friday 17th April Sealife Aquarium $25

SCHEDULED ACTIVITIES - Please select the activities you would like to participate in.*

Monday 19 January - Fairy Park, Anakie - Cost: $16.00Tuesday 20 January - Glow Show, Dance at Centre - Cost: FREEWednesday 21 January - Moonlit Sanctuary Wildlife Conservation Park - Cost: $17.00Thursday 22 January - Slippery Slime Lab / Ocean Adventure Treasure Hunt - Cost: FREEFriday 23 January - Melbourne Museum - Cost: FREE

SCHEDULED ACTIVITIES - Please select the activities you would like to participate in.*

Monday 26 January - Aussie Adventure Zone @ Centre - Cost: FREETuesday 27 January - Scienceworks (Last Day of Program) - Cost: FREE
*Suggested spending money.

Parent/Legal Guardian*
Relationship to the participant*
Phone*
Format: (000) 000-0000.
Email *
example@example.com
Emergency Contact Name (if parent or guardian is not available)*
Emergency Phone Number*

How did you hear about the School Holiday Program?*
To promote and grow the program, we require images of participants enjoying themselves. We would greatly appreciate it if we could share images of participants on social media and other publications.
I agree that photos of my child can be taken and used on social media and other publications.*

YesNo
I would like to obtain a post program report with images of my child at the program and agree to images to be taken for this purpose only*

YesNo

Please note a full risk assessment will be completed prior to the commencement of the program.
Year of last tetanus shot?*
Please indicate the usual level of care/support required by the child when in the community.*

1:31:21:1Other

Will the child require support with any of the following tasks?

Rows	Please provide details below
Eating
Drinking
Toileting
Communication
Other

Does the child use any mobility equipment?*

Manual WheelchairPowered WheelchairStrollerNone required
List any allergies and provide an anaphylaxis plan if applicable. *

NDIS Number*
Date the current NDIS plan Starts?*

DayMonthYear
Date
Date the current NDIS plan finishes?*

DayMonthYear
Date
What NDIS funding will you use for this program?*

CoreCapacity BuildingTransport
How is the above selected funding managed in your current NDIS plan?*

SelfAgencyPlan Manager
Payment Information

Details regarding payment will be sent once your registration has been approved.
PARTICIPATION RELEASE

By hitting submit and putting your initials, you agree that you are the parent or legal guardian of the above named participant and are over the age of 18.

I understand that the above named participant will only be released to the names listed above, an update may be done at registration.

I certify that my child has my permission to attend the program and participate in all activites. I hereby and forever release, discharge, indemnify and hold harmless Felicity Holistic Care and its employees and agents for any accidents, harm, loss or damage which my child may suffer or sustain in any way connected to the activities as a part of any school holiday program.

I am aware that your program, in addition to usual dangers and risks inherent, has certain additional dangers and risks, some of which may include: physical exertion for which my child may not be prepared, weather extremes subject to sudden and unexpected change, remoteness to normal medical services, evacuation difficulties if my child is disabled. I authorise staff, in the event of an accident or illness, to obtain all necessary medical assistance and treatment for my child and I agree to meet whatever cost may be incurred in respect of the provision of any necessary medical services. In the event of my child requiring medical attention I understand that the program workers will endeavour to communicate with me concerning the required action.

All Felicity Holistic Care services will require a service agreement and further information may be required.

I also agree that the Superheroes School Holiday Program staff are not responsible for theft of clothing or valuables during my child’s involvement in this program. The information I have provided on this form is correct.
Upload any relevant Documents

E.g. NDIS Plan, Asthma Plan, Medication Forms, Companion Card, etc.
Cancelof
Signature*
Should be Empty:

School Holiday Program Registration Form

Payment Information