Pre-School Age Friends Program

Pre-School Age Friends Program

Registration of Interest
Parent Name*

First NameLast Name
Parent Email*
example@example.com
Parent Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Child One (1) Name*

First NameLast Name
Child One (1) Date Of Birth*

DayMonthYear
Date
Please tick the level of support your child requires in the Pre-school Age Program*

One Staff Member to One Child Ratio (1:1 Support)One Staff Member to Two Child Ratio (1:2 Support)One Staff Member to Three Child Ratio (1:3 Support)
Has this child attended a WRTS Somerville Group Session before?*

YesNO (If not, we will be in touch to arrange an induction session)
Child Two (2) Name

First NameLast Name
Child Two (2) Date Of Birth

DayMonthYear
Date
Please tick the level of support your child requires in the program

One Staff Member to One Child Ratio (1:1 Support)One Staff Member to Two Child Ratio (1:2 Support)One Staff Member to Three Child Ratio (1:3 Support)
Has this child attended a WRTS Somerville Group Session before?*

YesNO (If not, we will be in touch to arrange an induction session)
Program you want your child to attend:*

Pre-School Age Friends Group - 2 hrs (Monday 9:00am-11:00am)Pre-School Age Friends Group 3 hrs (Monday 9:00am-12:00pm)Pre-School Age Friends Group 2 hrs (Wednesday 9:00am-11:00am)Pre-School Age Friends Group 3 hrs (Wednesday 9:00am-12:00am)
Type a question

Monday 2hrs - 9am-11amMonday 3hrs - 9am-12pmWednesday 2hrs - 9am-11amWednesday 3hrs - 9am-12pm
Please indicate frequency:*

WeeklyFortnightly
MEDICATION My child(ren) will require Medication to be administered by Support Staff during Sessions:
Does your child suffer from any known allergies?*

YESNO
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?*

YESNO
Has this happened before when your child was with you or in the care of others? If Yes please provide details.*

YESNO
If Yes please provide details:
I have reviewed the program of activities and feel that my child can participate with the following restrictions/adaptions/supports.
BEHAVIOUR CONCERNS: I understand that Management reserves the right to terminate services at any time due to behaviour concerns that may adversely impact the other children and staff. I will be advised verbally and in writing.*

YES
PRE-SHOOL AGE FRIENDS PROGRAM BOOKING CONDITIONS

I understand that by submitting this EOI Form, I am confirming my interest for the Pre-School Age Friends 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 Pauline Smales is NOT Licensed Childcare Provider. Government Fee assistance is NOT available.

I understand that this EOI form will serve as a Service Agreement for the Pauline Smales' Pre-School Age Friends Program 2025.

I understand that Pauline Smales is NOT a Registered NDIS Provider and therefore can invoice NDIS for those who are Plan Managed or Self Managed only.

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

https://form.jotform.com/242047452629862
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 Pauline Smales Cancellation Policy, as outlined below and agree to adhere to its terms.*

Cancellations more than 48 hours before the Service – Full Refund/No ChargeCancellations within 48 hours - 0% Refund/Full Payment (if participant's session can not be filled by another participant)NO SHOW - 0% Refund/Full PaymentAccounts Receivable Team will follow up any non payments in line with NDIS Policy and non payments will be reported to the NDIA.
Fees for 2025 Program are as follows and are based on the level of support your child requires:

2 Hr Program

1:3 Support $64.00
1:2 Support $95.00
1:1 Support $190.00
Customer Release of Liability, Indemnity Agreement, and Assumption of Risk for We Rock the Spectrum Facility which Host's Pauline Smales' Pre-School Age Program.
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)*
Date*

DayMonthYear
Date
Should be Empty: