We Rock Services (Berwick) - Health Information

We Rock Services - Health Information
Child's Name

First NameLast Name
Birth Date

DayMonthYear
Parent/Guardian Information
Name

First NameLast Name
Preferred Number

Area CodePhone Number
E-mail
Additional Contact

First NameLast Name
Additional Contact Number

Area CodePhone Number
Relationship
Does your child suffer from any known allergies? If so, please describe the reaction and the necessary treatment.
Please list interests or things your child likes doing.
Please list things that motivate or ways your child might be encouraged to participate.
Is your child toilet trained? Details, if required.
What is your child's preferred model of communication?
Does your child have physical limitations that we should be aware of?
Are there any behaviour or safety concerns that we should be aware of to help your child have a great time?
Will you be using NDIS funding?

YES - I am Self ManagedYES - I am NDIA ManagedYES - I am Plan ManagedNo
If using NDIS funding, what is your child's NDIS number?
Please note, additional We Rock the Spectrum NDIS service agreement must be completed.
I have reviewed the program and activities of WRTS and feel the child can participate without restrictions.

YESNO
I have reviewed the program and activities of WRTS and feel the child can participate with the following restrictions or adaptions.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, YOU ARE RECOGNISING THAT WE ROCK THE SPECTRUM KIDS GYMS ARE NOT LICENSED CHILDCARE FACILITIES.
Signature

Clear
Date

DayMonthYear
Date
Should be Empty:

We Rock Services - Health Information