WRTS SOMERVILLE Holiday Program Dec 2024

WRTS SOMERVILLE Holiday Program EOI DECEMBER 2024 - JANUARY 2025

Expression of Interest & Preferences Agreement & Health Form
Parent/Carer's Name:*

First NameLast Name
Phone Number*
Email*
example@example.com
Participant's One (1) Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
NDIS Number*
How is your NDIS Funding for WRTS Services Managed*
Please tick the level of support your child requires at the Kids Gym*

One Staff Member to One Child Ratio (1:1 Support)One Staff Member to Four Children Ratio (1:4 Support)
Has this child attended a WRTS Somerville Group Session before?*

YESNO (If not, we will be in touch to arrange an induction session)
Participant Two (2) Name (insert sibling's details if relevant)

First NameLast Name
Date of Birth

DayMonthYear
Date
NDIS Number
How is your NDIS Funding for WRTS Services Managed
Please tick the level of support the second child requires at the Kids Gym

One Staff Member to One Child Ratio (1:1 Support)One Staff Member to Four Children Ratio (1:4 Support)
Has the second child attended a WRTS Somerville Group Session before?

YESNO (If not, we will be in touch to arrange an induction session)
Please tick any date you are interested in your child attending:

MON 23 DEC CHRISTMAS CRAFT IN GYM Half day 9:30am-12:30pmTUES 24 DEC COOKIES FOR SANTA IN GYM Half day 9:30am-12:30pm
Notes if required:
Please tick any date you are interested in your child attending:

MON 6 JAN SMOOTHIE MAGIC IN GYM Half day 9:30am-12:30pmTUE 7 JAN BUILD & BOOGIE IN GYM Half Day 9:30am-12:30pmWED 8 JAN (ENCHANTED MAZE) Full Day Gym/Combo Session 9am-3pmTHU 9 JAN (PURE PENINSULA HONEY)Full Day in Gym Session 9am-3pmFRI 10 JAN LEGO WORKSHOP IN GYM Half Day 9:30am-12:30pm
Notes if required:
Notes if required:
Please tick any date you are interested in your child attending:

[HALF DAY] MON 13 JAN (COOKIE ART LAB) Gym/Combo Session 9:30am-12:30pm[HALF DAY] TUE 14 JAN (SUPERHERO TRAINING) IN GYM 9:30am-12:30pm[FULL DAY] WED 15 JAN (FUNKY FARM) Gym/Combo Session 9am-3pm[HALF DAY] THU 16 JAN (LAB LEGENDS) IN GYM 9:30am-12:30pm[FULL DAY] FRI 17 JAN (DINOSAUR WORLD) GYM/COMBO 9:00am-3:00pm
Please tick any date you are interested in your child attending:

[FULL DAY] MON 20 JAN (BRIARS BUSH WALK) Gym/Combo Session 9am-3pm[HALF DAY] TUE 21 JAN PAINT, PASTE & PLAY IN GYM 9:30am-12:30pm[FULL DAY] WED 22 JAN (DR HUBBLE BUBBLES) IN Gym Session 9am-3pm[HALF DAY] THU 23 JAN PIZZA PALOOZA IN GYM 9:30am-12:30pm[HALF DAY] FRI 24 JAN DANCE PARTY IN GYM 9:30am-12:30pm
Notes if required:
MEDIA CONSENT We occasionally post photos from the day on our Instagram and Facebook page to show the daily activities. No names are listed. Are you ok for your child’s image to be posted?*

YESNO
CANCELLATION POLICY I am aware of and agree to adhere to WRTS Australia's Cancellation Policy, as outlined below and agree to adhere to its terms. • Cancellations more than 48 hours before the Service – Full Refund/No Charge • Cancellations within 48 hours or NO SHOW - 0% Refund/Full Payment Required if participant's session can not be filled by another participant Please note: WRTS’s Accounts Receivable Team will follow up any non payments in line with NDIS Policy and non payments will be reported to the NDIA. A re-fund can be left as a credit on a client’s account for future services. Refunds or Credit can not be used for Rock Shop Products.*

Yes
NDIS GROUP PRICING GUIDELINE I understand that NDIS Pricing Guidelines require WRTS to outline our costs in our invoicing and separate out fees for Support hours, Gym Capital Costs, Non Face to Face Planning time and Travel Costs (where required). These line items will be outlined in our Group Invoices. These changes have in some cases altered the prices slightly. LACs, Plan Managers and Support Coords will be expecting these changes.*

I understand this Pricing Guidline
OUT-OF-POCKET ACTIVITY FEE. I understand that all COMBO Days and Community Excursions incur an out-of-pocket fee to cover excursion activities and costs that the NDIS do not cover eg. tickets, supplies. Each Excursion Out of Pocket Fee will now vary. The Out of Pocket fee for each day is indicated with a colour code on the program's flyer. This will be invoiced for separately and must be paid personally, not through funding, in a timely manner. The Out of Pocket Fee adheres to the same cancellation policy as above.*

Yes, I understand and accept
COMPANION CARD: If your child has a Companion Card, please upload a photo of the card here. To apply for a Companion Card visit https://www.companioncard.vic.gov.au/how-apply*

YESNO
Upload a copy of your Companion Card (if applicable)

Cancelof
MEDICATION My child(ren) will require Medication to be administered by WRTS SOMERVILLE during School Holiday Sessions:
Does your child suffer from any known allergies?*

NOYES
DIETARY REQUIREMENTS & ALLERGIES Some activities have a food element to them. Does your child have any allergies/intolerances? If so, please provide details.
If YES then please describe Allergy, Reaction and treatment (note if your child is Anaphylaxis we will require a Medical Management Plan and the Epi-pen will need to be brought to each session)
Please list interest or things your child likes doing
Please list things that motivate or ways your child might be encouraged to participate
Is your child toilet trained? Details if required.
What is your child's preferred model of communication?
Does your child have physical limitations we should be aware of?
Are they any behaviour or safety concerns that we should be aware of to help your child have a great time?
Upload a copy of your child's Behaviour Support Plan

Cancelof
Do you have any concerns about your child absconding from the Gym or during excursions? Has this happened before when your child was with you or in the care of others? If Yes please provide details.
I have reviewed the program of activities of WRTS and fell that my child can participate with the following restrictions/adaptions/supports.
HOLIDAY PROGRAM BOOKING CONDITIONS

I understand that by submitting this EOI Form, I am confirming my interest for We Rock the Spectrum - Somerville's School Holiday Program for the days and programs I have indicated above.

I understand that by submitting this Expression of Interest Form, I will be allocated as many sessions as possible, according to my wishes. I will receive a Booking Confirmation email outlining these sessions.

After my participant receives the services, I will be charged for each session.

I understand that We Rock the Spectrum Kids Gyms are NOT Licensed Childcare facilities. Government Fee assistance is NOT available.

I understand that this EOI form will serve as a Service Agreement for the WRTS Somerville December 24 - January 25 School Holiday Program.

I understand that I need to have completed a Service Agreement & Schedule of Supports to enable WRTS to invoice for NDIS funds to cover this program via the below link:

https://form.jotform.com/242047452629862
Additional notes:
Customer Release of Liability, Indemnity Agreement, and Assumption of Risk
In consideration of being permitted by We Rock the Spectrum Kid’s Gym (hereinafter “WRTS”) to participate in its activities and to use its equipmentand facilities, now and in the future, I as parent or legal guardian of the child/ren [named at the bottom of this document] a minor (hereinafter “Minor”),hereby grant the permission necessary to allow Minor to participate in all activities at this WRTS location and agree with all the terms of this Releaseof Liability, Indemnity Agreement, and Assumption of Risk Agreement (hereinafter “Agreement”). I, in my own behalf and on behalf of Minor,further agree to release, indemnify and discharge WRTS, its agents, owners, shareholders, directors, partners, employees, volunteers,manufacturers, participants, lessors, affiliates, its subsidiaries, related and affiliated entities, successors and assigns (hereinafter “Released Parties”),on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and estate as follows:*

I understand and acknowledge that the activity the Minor is about to voluntarily engage in as a participant bears certain known risks and unanticipated risks which could result in physical, emotional, or mental injury, paralysis, illness or disease, death, or damage to Minor, to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activities at WRTS. The risks include, among other things: Use of WRTS equipment entail certain risks that simply cannot be eliminated without jeopardizing the essential qualities of the activity. Use of equipment may expose participants to the usual risk of cuts, scrapes, bruises, and rug burns. Other more serious risks exist as well. Participants may fall off equipment, sprain, injure, or break fingers, toes, wrists, feet, legs, back, or neck, and can suffer more serious bodily injuries as well. In any event, if Minor is injured and may require medical assistance, you as parent or legal guardian will assume full liability and responsibility for the expenses.Furthermore, WRTS employees have difficult jobs to perform. They seek safety, but they are not infallible. They might be unaware of a participant’s fitness or abilities. They may give incomplete warnings or instructions, and the equipment being used might become loose, out of adjustment, or malfunction. There is also a risk that WRTS employees may be negligent in, among other things, monitoring and supervising use of its equipment and facilities and in the maintenance and repair of its equipment and facilities.I agree that this Release of Liability, Indemnity Agreement, and Assumption of Risk Agreement is made on behalf of that Minor participant and that all of the releases, waivers and promises herein are binding on that Minor participant. I represent that I have full authority as Parent or Legal Guardian of the minor participant to bind the Minor participant to this Agreement.I expressly agree and promise to accept and assume all of the risks existing in this activity on behalf of Minor. The Minor’s participation in this activity is purely voluntary, and I elect to have Minor participate in spite of all the risks.I hereby voluntarily release, forever discharge, and agree to defend, indemnify and hold harmless WRTS and all Released Parties from any and all claims, demands, or causes of action, which are in any way connected with Minor’s participation in this activity or use of WRTS equipment or facilities, including any such claims which allege negligent acts or omissions of Released Parties.I indemnify and save and hold harmless WRTS and the Released Parties against any loss, liability, damage or cost that may incur arising out of or in any way connected with the Minor’s use of WRTS equipment or gear provided therewith or any acts or omissions of the Released Parties.Should WRTS or anyone acting on its behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs. This means that I will pay all of those attorney’s fees and costs myself.I certify that I have adequate insurance to cover any injury or damage that Minor may cause or suffer while participating in all WRTS activities, or else I agree to bear the costs of such injury or damage to Minor myself. I further certify that I am willing to assume the risk of any medical or physical condition that Minor may have.I expressly agree that this Agreement is governed by the State of Victoria, Australia and is intended to be as broad and inclusive as permitted by Victorian and Australian law, and that in the event any portion of this Agreement is determined to be invalid, illegal, or unenforceable, the validity, legality and enforceability of the balance of the Agreement shall not be affected or impaired in any way and shall continue in full legal force and effect. In the event that I file a lawsuit against WRTS, I agree to do so solely in the State of Victoria, Australia and I further agree that the substantive law of the State of Victoria, Australia shall apply in that action without regard to the conflict of the law rules of that state.I further agree to defend, indemnify and hold harmless WRTS from any and all claims or lawsuits for personal injury, property damage or otherwise which are brought by, or on behalf of the Minor, and which are in any way connected with such use or participation by the Minor, including injuries or damages caused by the negligence of Released Parties, except injuries or damages caused by the sole negligence or wilful misconduct of the party seeking indemnity.I certify that, to the best of my knowledge, the Minor does not have a health condition that would make it inadvisable for the Minor to participate in WRTS activities.I agree to grant WRTS and all Related Parties, the irrevocable right and permission to photograph and/or record me or Minor in connection with WRTS to use the photograph and/or recording for all purposes, including advertising and promotional purposes, in any manner in any and all media now or hereafter known, in perpetuity throughout the world, without restriction as to alteration. I waive any right to inspect or approve the use of the photograph and/or recording and acknowledge and agree that the rights granted to this release are without compensation of any kind. All photographs and/or recordings are exclusive to WRTS.In consideration of not being required to sign a fresh copy of this Agreement before each visit, I further agree that this Agreement shall apply to all future visits of the Minor to this WRTS location.By signing this Agreement, I acknowledge that I have had sufficient opportunity to read this entire Agreement, I understand it completely, I understand that it affects my legal rights, and I agree to be bound by its terms. I also agree if anyone is hurt or property damaged during the Minor’s participation in this activity, I may be found by a court of law to have waived my or the Minor participant’s right to maintain a lawsuit against WRTS and the Released Parties on the basis of any claim from which I have released them herein.By signing this agreement, you are acknowledging that We Rock the Spectrum Kids Gym is not a licensed Child Care.
By Signing this I agree to all Booking Conditions stated above: (PLEASE ENSURE YOU PRESS SUBMIT WHEN FINISHED)*

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WRTS SOMERVILLE Holiday Program EOI DECEMBER 2024 - JANUARY 2025

Customer Release of Liability, Indemnity Agreement, and Assumption of Risk