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.Format: 0000 000 000.
Email
example@example.com
Participant's Representative (if applicable)

First NameLast Name
Relationship
Parent, guardian, representative
Phone Number
Please enter a valid phone number.Format: 0000 000 000.
Email
example@example.com
Participant Manager Details
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: 0000 000 000.
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
Price/Unit of Measure
Price/Unit of Measure
Price/Unit of Measure
Day of Week
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
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
NDIS Plan

Cancelof
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