After school program 2024

1

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

YESNO

2

Child Name* This field is required.

First Name

Last Name

3

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

YESNO

4

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

5

Primary Carer Name* This field is required.

First Name

Last Name

6

Primary Carer Email* This field is required.

example@example.com

7

Primary Carer Phone Number* This field is required.

Please enter a valid phone number.

8

Date of Birth * This field is required.

Date

9

Gender* This field is required.

Male

Female

Other

10

Is the child considered* This field is required.

An Aboriginal

No

Torres Strait Islander

11

Child Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

12

School* This field is required.

13

Diagnosis* This field is required.

14

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

15

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

16

Self feeding* This field is required.

YESNO

17

Self toileting* This field is required.

YESNO

18

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

YESNO

19

NDIS Number* This field is required.

20

The plan is* This field is required.

Self-managed

Plan Managed

21

Billing Email* This field is required.

example@example.com

22

Cultural Background* This field is required.

23

Dietary Requirements* This field is required.

24

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

25

After school dates* This field is required.

26

Picking up from* This field is required.

The school

Bus stop

27

Pick up Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

28

Pick up Time * This field is required.

29

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

30

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

YESNO

31

Behaviours of concerns* This field is required.

Absconding

Self harm

Harming others

others:

32

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

YESNO

33

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

YESNO

34

Kindly upload it* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

35

Allergy cause* This field is required.

36

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

37

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

YESNO

38

Kindly upload the plan* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

39

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

YESNO

40

Medication Name* This field is required.AS Labelled

41

Dosage given:* This field is required.

As prescribed by the doctor

As instructed on the packaging

As needed.

42

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

43

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

YESNO

44

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

45

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

46

Billing Out of ?* This field is required.

Core Funding : Social activities

Capacity building: Therapy

47

Emergency Contact Name* This field is required.

First Name

Last Name

48

Emergency Contact Phone Number* This field is required.

Please enter a valid phone number.

49

Form filled by:* This field is required.

First Name

Last Name

50

Date* This field is required.

Date