• NDIS: iROCK-Participant Service Agreement

  • Your enrolment with us has been pre-approved by your plan manager, support coodinator and/or NDIA through their acceptance of the quote we sent previously. Before we can proceed with your enrolment we require some additional information in order to set up the Service Agreement between us and you, as required by NDIS guidelines.

    Please read and complete the Service Agreement form that follows carefully, being certain to fill all required fields. Click the links to read our Ts & Cs, Privacy Policy and Media Consent before accepting, and then sign and date to finalise.

    We will not be able to process or confirm your enrolment with us until we receive the signed and accepted Service Agreement. Once received, our Operations team will double check all details and finalise your enrolment. If we have no further questions we will forward you a signed copy of the final agreement when processed. Your sessions will be scheduled to begin shortly after this.

    Please let us know if you have any questions and we look forward to receiving all the necessary paperwork from you shortly. We can't wait to get started with some rockin' music sessions with you at iROCK soon!

  • Participant/Client Details

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  • Parent/Guardian

    Emergency Contact Details

  • Parent/Guardian 2

    Emergency Contact Details (if Applicable)

  • Participants Nominee (If Applicable)

  • NDIS Details

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  • Plan Manager Details

  • Support Coordinator Details

  • Supports Required

    If Applicable

  • Medical Information

    Please outline the diagnosis of the participant.

  • Other Information

    e.g. Behavioural supports, communication supports, visual aides, learning styles etc.

  • Please Note: The services outlined here are to be provided in accordance with the Terms & Conditions linked and outlined below.

  • iROCK Music School Details

    Business Name: iROCK Music School
    Company Name: iROCK Music Pty Ltd
    ABN: 99 650 898 098
    Director/Owner: Jerry Trzeciak
    NDIS Representative: Sam Allcock (Operations Manager)
    Address: 9a Whitfield Drive
    Cranbourne West
    VIC 3977
    Phone: 1300 047 625
    Email: operations@irockmusicschool.com.au
    Website: iROCK Music School

  • Service Agreement Period (Read Only)

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  • Please Note: a one time sign up fee of $25 is applied to your first invoice.

  • General Summary of Supports and Services

    Please Note: This summary pertains to your first invoice.
    Ongoing costs for subsequent terms/months may vary based on term length.

     

    Item Number: 04_210_0125_6_1
    Item Details: Community, Social and Recreational Activities

    Information on Support:

    This support item is designed to enable providers to claim reimbursement for the costs of enabling a participant to independently engage in community, social and recreational activities when costs of participation exceed an affordable level and without, the participant would be at risk of social isolation. Participants may use this funding for activities such as camps, vacation and outside school hours’ care, course or membership fees. This support item can be delivered to individual participants subject to the rules set out in the NDIS Pricing Arrangements and Price Limits.

    Purpose: CORE
    Outcome Domain: Social and Community Participation
    Support Category: 1.04 Assistance with Social, Economic and Community Participation

  • Agreement and Acceptances

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  • Please read the following documents, and declare that you have read and accept our NDIS Service Agreement, iROCK Music School Terms and Conditions, iROCK Music School Privacy Policy and either approve or deny your consent to the below statements. You can access all the mentioned below:

    1. NDIS Service Agreement Terms and Conditions

    2. iROCK Music School Terms and Conditions

    3. iROCK Music School Privacy Policy

     

     

  • Please Note: Media Consent can be revoked at any time by contacting us.

  • Clear
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  • Please Note: In the case of a participant's funds being insufficient through the NDIS, payment of session fees will become the responsibility of the individual client or family.

  • Hi Rob. This is all looking really good. Bit more work to go on this one to complete.

    The info below needs to be added to this form using the appropriate fields etc. some of it will be paragraph type text like at the top and there are at least 4 links that need to be in here too. I've removed the Support Plan item as the request for them to complete that can be sent after we receive this (I wrote this in the flow chart for NDIS forms)

    Agreement and Acceptances

    iROCK Music School (Us) Drop Down: Jerry Trzeciak, Sam Allcock We sign here
    Drop Down: Director/Owner, NDIS Representative Date
    Participant/Nominee (You) Name Enter Name here
    NDIS Service Agreement Terms & Conditions Accepted Drop Down: Yes
    iROCK Music School Terms & Conditions Accepted Drop Down: Yes
    Privacy Policy Accepted Drop Down: Yes
    "Media Consent:
    Consent to photograph, video and/or audio record
    Consent to use first names alongside media or as part of embedded text
    Consent to use media (photo, film, audio) in promotional materials, social media and/or online" "
    Drop Down: Yes, No
    Drop Down: Yes, No
    Drop Down: Yes, No"
    Please Note: Media Consent can be revoked at any time by contacting us.
    Signature You sign here
    Date
    "Please Note: In the case of a participant’s funds being insufficient through the NDIS,
    payment of session fees will become the responsibility of the individual client or family."

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