Sapience Care Services - Service Agreement

Sapience Care Services - Service Agreement
Between:
Name (Participant)*

First NameLast Name
Date of Birth*

DayMonthYear
Date
NDIS Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Participant's Representative (if applicable)

First NameLast Name
Relationship
Parent, guardian, representative
Phone Number
Please enter a valid phone number.
Email
example@example.com
Participant Manager Details
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
AND
Company: Sapience Care Services PTY LTD

ABN: 67688627787

Address: 79 William street Cobram 3644

Contact details:

0401 905 256

Admin@sapiencecare.com

The Organization hereby agrees to carry out and/or provide the Supports for the Participant in accordance with the Schedules and the Terms attached to this Agreement.
Price & Payment Information
Funding Category*
Service Type*

Assistance with Household TasksOutreachCommunity EngagementShort Term Accommodation (STA)Transportation AssistanceEducation SupportOvernight ShiftsGroup Activities
Price/Unit of Measure*
Price/Unit of Measure
Price/Unit of Measure
Day of Week*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Time*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Time

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Time

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Frequency*
Method of Payment*

Self managedPlan-managed
Additional Notes
Terms and Conditions
Consent is given for Sapience Care Services to take and use photos of the participant for documentation, social media, or promotional purposes*

YesNo
Executed as an Agreement
Date*

DayMonthYear
Date
Signature of Participant/Guardian*

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Sapience Care Services - Service Agreement

Participant Manager Details

Price & Payment Information

Terms and Conditions

Executed as an Agreement