After school program 2024

1

Follow us to get the latest news about our exciting adventuresjoin our Wonder Family

2

Are you new to the Wonder Family?* This field is required.

YESNO

3

Child Name* This field is required.

First Name

Last Name

4

Any Changes from the last activity booking?* This field is required.

YESNO

5

Kindly let us know the changes from the last booking* This field is required.

6

Primary Carer Name* This field is required.

First Name

Last Name

7

Primary Carer Email* This field is required.

example@example.com

8

Primary Carer Phone Number* This field is required.

Please enter a valid phone number.

9

Date of Birth * This field is required.

Date

10

Gender* This field is required.

Male

Female

Other

11

Is the child considered* This field is required.

An Aboriginal

No

Torres Strait Islander

12

Child Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

13

School* This field is required.

14

Diagnosis* This field is required.

15

Sensory Preferences (likes, enjoys and calm them down)* This field is required.

16

Sensory Triggers (avoids, dislikes and triggers them)* This field is required.

17

Self feeding* This field is required.

YESNO

18

Self toileting* This field is required.

YESNO

19

Is the child an NDIS participant?* This field is required.

YESNO

20

NDIS Number* This field is required.

21

The plan is* This field is required.

Self-managed

Plan Managed

22

Billing Email* This field is required.

example@example.com

23

Cultural Background* This field is required.

24

Dietary Requirements* This field is required.

25

The Care ratio* This field is required.No Activity fees will be included

1:1 = 65$/hr + centre capital cost 2.50$/hr+ Non face to face support

1:2 =40$/hr + centre capital cost 2.50$/hr+ Non face to face support

26

After school dates* This field is required.

27

Picking up from* This field is required.

The school

Bus stop

28

Pick up Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

29

Pick up Time * This field is required.

30

By selecting YES, I am accepting to pay my child`s activities fees out of pocket before the school holidays out of pocket NOT of the NDIS funding. * This field is required.you will receive an invoice not related to NDIS

YESNO

31

Any Behaviours of concerns?* This field is required.IF you choose (YES) , your child is required to be 1:1

YESNO

32

Behaviours of concerns* This field is required.

Absconding

Self harm

Harming others

others:

33

Any Positive Behaviour Support plan ?* This field is required.

YESNO

34

Any allergies?* This field is required.* If yes, kindly fill the allergies form

YESNO

35

Kindly upload it* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

36

Allergy cause* This field is required.

37

Allergy signs and symptoms* This field is required.ex: rashes, swelling, sweating..

38

is there any anaphylaxis/allergy plan?* This field is required.

YESNO

39

Kindly upload the plan* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

40

Any medications?* This field is required.*If the child needs to be given medication during the session or in case of emergency

YESNO

41

Medication Name* This field is required.AS Labelled

42

Dosage given:* This field is required.

As prescribed by the doctor

As instructed on the packaging

As needed.

43

By selecting YES, I am giving my consent for the staff at Wonder Kidz to administer medication to my child as outlined above.* This field is required.

YESNO

44

Transportaion?* This field is required.travel time plus 1$ per 1 Km

YESNO

45

By selecting YES, I am giving my consent for the staff at Wonder Kidz to transport my child in their vehicle.* This field is required.

YESNO

46

Transportaion?* This field is required.

WK Staff Pick Up from home only

WK Staff Drop Off home only

Parents will Drop off

Parents will pick up

Other

47

Billing Out of ?* This field is required.

Core Funding : Social activities

Capacity building: Therapy

48

Emergency Contact Name* This field is required.

First Name

Last Name

49

Emergency Contact Phone Number* This field is required.

Please enter a valid phone number.

50

Form filled by:* This field is required.

First Name

Last Name

51

Date* This field is required.

Date