Gritlife new client registration form

1
Who’s the care for?* This field is required.
Myself
Someone else
2
What is your relationship to them?* This field is required.
Carer
Guardian
Support Coordinator
Medical Professional
3
Name of Adventure?* This field is required.
4
Adventurer's Date of birth DD/MM/YYYY
5
Contact Details* This field is required.
6
Emergency Contact Details* This field is required.
7
How would you like to pay?* This field is required.
My support will be covered by NDIS
I will pay with my own money
8
To help us support you better, could you please share the condition(s) related to your NDIS plan?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
9
To help us support you better, could you please share any condition(s) or disabilities that we should be aware of?
Huge
Large
Normal
Small
Ok
Ok
10
NDIS participant number* This field is required.
11
How is your plan managed?* This field is required.
Plan Managed
Self Managed
12
Who is your plan manager * This field is required.
13
Do you have any medical conditions or allergies we should be aware of?* This field is required.
Yes
No
14
What are these conditions/allergies?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
15
Do you have any physical limitations or mobility concerns?* This field is required.
Yes
No
16
What are these and how do they affect you?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
17
Are you currently taking any medications?* This field is required.
Yes
No
18
Medications * This field is required.
Huge
Large
Normal
Small
Ok
Ok
19
Do you require any special accommodations or support during activities?* This field is required.
Yes
No
20
Special accomodations/support needed * This field is required.we want to know how we can make your adventure a smooth time
Huge
Large
Normal
Small
Ok
Ok
21
Do you have a preference for your carer's gender?* This field is required.
Male
Female
No preference
22
What’s one thing you have done recently that you are proud of?Tell us about an accomplishment or experience that made you feel proud. Helps us understand what motivates you
Huge
Large
Normal
Small
Ok
Ok
23
What are your personal goals for the next 6 months?Share your goals and aspirations with us. Knowing what you aim to achieve helps us tailor your journey
Huge
Large
Normal
Small
Ok
Ok
24
What motivates you to participate in adventurous activities?Let us know what drives your interest in adventure
Huge
Large
Normal
Small
Ok
Ok
25
I consent to the collection and use of my personal information in accordance with GritLife’s privacy policy* This field is required.https://docs.google.com/document/d/1tci5MCTUKNpYpR6FVTMoskt-AkpogiGMciZnhyQGVno/edit?usp=sharing
Yes
26
I agree to the Terms and Conditions of Gritlife's services* This field is required.https://docs.google.com/document/d/1QOlVBXMJR_bpuJiMVEekY4jjsuLfAGpq88NcNO0qt2c/edit?usp=sharing
Yes
27
Service Agreement SignatureBy signing below, you are agreeing to the terms and conditions outlined in the GritLife Service Agreement. This agreement will be automatically populated with the information you provide in this form. Once completed, a copy of the finalised agreement will be emailed to you. Please review the GritLife Service Agreement before signing.
Powered by Jotform SignClear
28
How did you hear about us?Letting us know how you found out about us helps to bring this opportunity to more people
Please Select
Please Select
Facebook (ndis group)
Facebook advertisment
Contact from a Gritlife staff member
Word of mouth
other
Should be Empty: