NDIS Registration Form

Camp Kiah Camper NDIS Registration Form
All campers must be registered at www.campkiah.com.au/register.

This form is to be completed in addition by families accessing Camp Kiah through NDIS funding.
Young Person Details

(Participant details)
YPID
Young Person Name*

First NameLast Name
Date of Birth*

DayMonthYear
NDIS Number*
NDIS Plan Expiry*

DayMonthYear
NDIS Plan Manager*
NDIS Plan Manager Phone*
NDIS Plan Manager Email*
NDIS Goals*
Diagnosis*
NDIS Plan

Optional
Cancelof
Does your young person require a social story?*
As part of the NDIS provider responsibilities Camp Kiah is required to provide participants with adequate information to allow participants to access, engage and navigate our service. Information regarding the following topics can be found in our NDIS Orientation Pack;
- NDIS specific registration form
- Consent to share information
- Consent to share information form
- Information storage
- Service Agreements
- Complaint Policy
- Complaint Form
- Advocacy and Support
- Cancellation Policy
- Camp Kiah Child Protection Policy
- Eliminating restrictive practices
- ASD & Camp Kiah
Further information can be found on our website www.campkiah.com.au/ndis
I have accessed and viewed the Camp Kiah NDIS Orientation Pack*
Support Coordination
Support Coordinator Name

First NameLast Name
Support Coordinator Phone
Please enter a valid phone number.
Support Coordinator Email

Communication
Does the Young Person require communication assistance?*
Please explain what assistance they require
Behaviour
What are the current Behaviours of Concern (BOC)?*
If there are no current BOC please enter N/A
Does the Young Person have a behaviour support practitioner?*
Behaviour Specialist

First NameLast Name
Behaviour Specialist Phone
Please enter a valid phone number.
Behaviour Specialist Email
What is the expiry date of your current Behaviour Support Plan?

DayMonthYear
Date
Please upload your current Behaviour Support Plan

Cancelof
Medication
Does the Young Person take medication?*
Please list medications
Restrictive Practices
Does the Young Person have restrictive practices?*
Please tick the restrictive practices that apply

Chemical restraintsMechanical restraintsEnvironmental restraintsPhysical restraintsSeclusion
Mealtime Management
Does the Young Person have a mealtime management plan?*
Please give details
Should be Empty:

Camp Kiah Camper NDIS Registration Form