NDIS Participant Approval Form

NDIS Participant iROCK Music Application
Thank you for your recent inquiry into the music services we offer for NDIS Participants at iROCK Music School. We are excited to hear that you wish to enrol and can't wait to get you started. Before we can proceeed we need to collect some more information from you for quoting and invoicing purposes. Payment for your sessions with us must be pre-approved by the NDIA, your Plan Manager or Support Coordinator (if applicable). Please return this form at your earliest convenience so that we can proceed with sending your quote off for approval.
Participant/Client Details
Primary Email Address (The email you wish to receive information and updates from us)*
You will be required to create a free Jot Form account to access future incoming NDIS forms from us.
Participants Name

First NameLast Name
Participants Phone Number (If applicable)
Please enter a valid phone number.
Participants Email (If Applicable)
example@example.com
Participants DOB

MonthDayYear
Date
Participants Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian

Emergency Contact Details
Parent/Guardian Name

First NameLast Name
Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Phone Number
Please enter a valid phone number.
Parent/Guardian Email
example@example.com
Add Secondary Contact?

YesNo
Parent/Guardian 2

Emergency Contact Details (if Applicable)
Parent/Guardian 2 Name

First NameLast Name
Parent/Guardian 2 Phone Number
Please enter a valid phone number.
Parent/Guardian 2 Email
example@example.com
Parent/Guardian 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Add Participant Nominee?

YesNo
Participants Nominee (If Applicable)
Nominee Name

First NameLast Name
Nominee Phone Number
Please enter a valid phone number.
Nominee Email
example@example.com
Nominee Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
NDIS Details
NDIS Number*
Plan or Self Managed*

PlanSelf Managed
Support Coordinator*

YesNo
Plan Start Date*

MonthDayYear
Date
Plan Review Date*

MonthDayYear
Date
Medical Information

Please outline the diagnosis of the student.
Medical Diagnosis
Other Information

e.g. Behavioural supports, communication supports, visual aides, learning styles etc.
Additional requirements for participant
Plan Manager Details

If Applicable
Plan Management Business Name
Plan Management Contact Person
Plan Management Email
example@example.com
Plan Management Additional Email (If Applicable)
example@example.com
Plan Management Phone Number
Please enter a valid phone number.
Billing

Pre SessionPost Session
Support Coordinator Details

If Applicable
Support Coordinator Business Name
Support Coordinator Contact Person
Support Coordinator Email
example@example.com
Support Coordinator Phone Number
Please enter a valid phone number.
Support Coordinator Phone Number (Additional)
Please enter a valid phone number.
Supports Required

If Applicable
Support Worker Name
Additional information for support worker if applicable
Should be Empty:

NDIS Participant iROCK Music Application

Participant/Client Details

Parent/Guardian

Parent/Guardian 2

Participants Nominee (If Applicable)

NDIS Details

Medical Information

Other Information

Plan Manager Details

Support Coordinator Details

Supports Required