FHC Superheroes

School Holiday Program Registration Form

Facilitated by Felicity Holistic Care.

Participant Information
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 Information
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 Week - 1 (September 22nd to September 26th)
SCHEDULED ACTIVITIES - Please select the activities you would like to participate in.*

Monday 22nd September – Melbourne Zoo (Visit the Baby Giraffe) - FreeTuesday 23rd September – Bouncy Roo's Werribee – $14.99Wednesday 24th September - Arts and Crafts at Manly St followed by Scavenger hunt at Werribee park - FreeThursday 25th September – Picnic at Serendip Sanctuary (BYO Lunch) - FreeFriday 26th September – Public Holiday - AFL Grand Final - Closed

Scheduled Activities Week - 2 (September 29th to October 3rd)
SCHEDULED ACTIVITIES - Please select the activities you would like to participate in.*

Monday 29th September - Myuna Farm Doveton - $10Tuesday 30th September – Swimming at Laverton Swim & Fitness Centre - $7Wednesday 1st October – SEA Life Melbourne – $37.50Thursday 2nd October - Sports Day at Maddingley Park - FreeFriday 3rd October - Flip Out Derrimut- $26
*Suggested spending money.

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

Other Information
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

Health & Support Information
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?

	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 Information
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*

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School Holiday Program Registration Form

Payment Information