Assistance For STA

Let's begin - who is making this enquiry?*

Participant First Name*

First Name

and Last Name*

Last Name

Participant Email (if applicable)

example@example.com

Participant Phone (if applicable)

Please include your area code ie. (03) if applicable

Now, what is your role?*

Your First Name*

Your Last Name*

Your Email*

example@example.com

Your Phone*

Please include your area code ie. (03) if applicable

Check your eligibility for STA prior to completing this form (Short Term Accommodation)*

You may be asked to submit this form and redirected to an external website depending on your answer

Please press "Submit" to check your eligibility

Which organisation do you work for?*

Who should we contact to make this booking?*

Support Co-ordinator First Name (if applicable)

First Name

and Support Co-ordinator Last Name (if applicable)

Last Name

Support Co-ordinator Phone (if applicable)

Please include your area code ie. (03) if applicable

Support Co-ordinator Email (if applicable)

example@example.com

Your State or Territory?*

Do you know the dates needed for the stay (or best approximate)?

Yes - choose dates (minimum 2 night booking)No / Flexible - comment below

So we can assist you until dates are confirmed, please provide as much information as possible - e.g. Number of nights, flexible dates etc.

E.g. 5 nights anytime in June

Arrival date (or best approximate)*

DayMonthYear

Departure date (or best approximate)*

DayMonthYear

Preferred location(s)*

(Suburb/Town - please include State)

Would you like to book a particular property?

E.g. Property name

Preferred property type (select all that apply)*

Centre or group based accommodationPrivate accommodationOther (please comment below)

Prop type - Hidden

How many bedrooms are required?

What level of support is required?*

STA funding will not cover overnight bedding costs in private accommodation.

How will this accommodation assist with your plan goals?*

So we can better assist you, please briefly describe the purpose of your stay

Does the participant have any sensory processing or behavioral considerations we need to be aware of to assist in sourcing the most appropriate accommodation?*

Please provide a brief description

Do you currently have a Behavioural Support Plan or an OT assessment available?*

Please upload if available or send through to contact@medistays.com.au

Accessibility Requirements*

Is car-parking required for participant or supports? (STA funding will not cover the cost of carparking)*

Is pet friendly accommodation required?*

How about funding?*

Funding is...*

Any extra funding comments

Plan Manager (if applicable)

Is there anything else we can assist you with to achieve the best outcome for your booking?

Would you like this booking repeated?

How did you hear about MediStays?*

Newsletter

Yes, subscribe me to the MediStays newsletter

Please verify that you are human*

Newsletter response based on Opt-In tick above for Monday (Hidden)

Yes, subscribe me to the MediStays newsletterNo

Opt-out responses for Monday newsletter (Hidden)

No

This is just for categorising in Monday - Hidden

This is just for categorising ineligible in Monday - Hidden

Not used - Support Co-ordinator Name (if applicable)

First NameLast Name

Paticipant full name - for Monday ITEM Column (Hidden)

Firstly, Participant Name (not used - replaced with split name field)

First NameLast Name

MC FNAME (Hidden)

MC LNAME (Hidden)

MC EMAIL (hidden)

example@example.com

STATIC TAGS (Hidden)

DYNAMIC TAGS (Hidden)