Fitness Care Participant Details

Your Email*

example@example.com

Participant Name*

First NameLast Name

Participant Date of Birth*

Participant NDIS Number if applicable*

Please specify if you're not an NDIS participant

How are the participants funds managed?*

Invoice email for self managed or self funded & plan managed clients. If agency managed please specify.*

Please include invoice

Participants &/or plan nominee name & contact phone number*

Participant &/or plan nominee email address*

Address of the participant*

Participant Suburb*

Participant Postcode*

Participant State*

Participant Diagnosis*

Participant Gender*

Please mention any additional details such as current gym or fitness memberships, where participant would like support facilitated, any challenging behaviours, behaviour support plan details, risk assessments, risk management strategies, relevant restrictive practices, allergies, cultural values, beliefs or any additional details that would help us provide services e.g food allergies, violent outbursts, triggers, risks in home etc...*

Would you like us to use Core or Capacity Building to deliver our service?*

If the budget selected isn't available and services are delivered we will use budget available from categories within the service agreement.

Availability for sessions or respite - please list days, times and where participant would like support to be facilitated*

Please tell us about your goals & what you are hoping to get out of the service.*

If filling out on behalf of a participant please specify the participants goals.

Please feel free to upload any additional details that would help us provide support such as NDIS plan or management plans (Optional)

Signature*