Summer Events Program Service Agreement

USS Spring Events EOI

Ulladulla Support Services provides opportunity for people to come together and experience new opportunities and experiences through our group programs Each program runs for a 3 month period. Please complete the form to join in the fun!
Participant Information
Participant's Name

First NameLast Name
Gender

MaleFemaleOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Summer Group Events You Wish To Attend

Easy Eats - Cooking Class (1st Tuesday of Month)Courtside Connections- Tennis (2nd Tuesday of Month)Mugs & Masterpieces (3rd Tuesday of Month)Float & Flow - Social Swim (4th Tuesday of Month)Wednesday Fortnightly Friendship Dinner6th September Footy Trip16th October Shellharbour Shopping Trip
Important Information
Do you require transport

YESNO
Do you have any allergies, chronic illness, medical conditions or specific food requirements? If yes, please describe.
NDIS Plan Information
Are you a current Ulladulla Support Service Participant

YesNo (please fill out below NDIS Plan information)
NDIS Number
Plan Start Date

MonthDayYear
Date
Plan End Date

MonthDayYear
Date
Plan Manager
Email
example@example.com
Consent

I hereby give my consent to participate in said USS Group Program.

I am aware my details are held on an electronic Client Management System and consent to the storage of my personal information on Ulladulla Support Services Databases.

Service Agreement

You will recieve a Service Agremeent for the 3 month period of the USS Summer Events program.

This Service Agreement will be based on the events you have expressed an EOI to attend.

All group programs are billed as per NDIS guidelines on ratio of staff:participant in attendence.

NDIS Cancellation guidelines of 7 business days occurs.

Quoted hours on Service Agreement include Activity, Travel and Non Face to Face Preparation Time.

Once the Service Agreement is Signed by yourself and returned to USS, it will be sent to your plan manager to complete a service booking.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Participants Signature

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USS Spring Events EOI

Participant Information

Important Information

NDIS Plan Information