Camp Kiah NDIS Service Agreement

NDIS Service Agreement

This Service Agreement is made between

Provider
ABN	Contact
15 615 893 091	PO Box 363, Wallan Vic 3756
Phone	Email
0490 252 518	maree@campkiah.com.au
and

YPID
Young Person Name*

First NameLast Name
Date of Birth*

DayMonthYear
NDIS Plan Number*
Phone Number*
Please enter a valid phone number.
Representative Name*

First NameLast Name

Camp 1
What Program is your participant attending?
Program
RatioOptions
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Camp
Theme
Days
Support Ratio
Support Ratio
Support Ratio
Camp Name
LookupKey 1
Cost
Cost
Amount
NDIS Line Items – Core
NDIS Line Items – Capacity
Program 1 Details
Program 1 Ratio
Would you like to add another program?*

YesNo

Camp 2
What Program is your participant attending?
Program 2
RatioOptions 2
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Days
Program 2: Support Ratio
Program 2: Support Ratio
Program 2: Support Ratio
Camp Name 2
LookupKey 2
Cost 2
Cost 2
Program 2: Amount
NDIS Line Items – Core
NDIS Line Items – Capacity
Program 2 Details
Program 2 Ratio

Program 3
Program 3: Details
Program 3: Start Date

DayMonthYear
Date
Program 3: End Date

MonthDayYear
Date
Program 3: Days
Program 3: Ratio
Program 3: Cost per 24 hours / camp
Program 3: Amount
NDIS Line Items – Core
NDIS Line Items – Capacity
Total Amount

Does the participant require an NDIS Report before their plan review?*
What is the review date for their NDIS Plan?

DayMonthYear
Service
Amount

Ending this Service Agreement

Service agreements begin from the date of program attending and end the day after the program completes.

Should either you or Camp Kiah wish to end this Service Agreement, one month’s notice must be given in writing. If there is a serious breach of this Service Agreement by either you or Camp Kiah, the requirement of the notice will be waived.

Responsibilities of Camp Kiah

Camp Kiah agrees to:

Communicate openly and honestly and in a timely manner
Treat the Participant and/or the Participant’s representative with courtesy and respect
Consult the Participant and/or the Participant’s representative on decisions about how supports are provided
Give the Participants and/or the Participant’s representative the required notice if Camp Kiah needs to end the Service Agreement
Protect the Participant’s privacy and confidential information
Provide the Participant with details of any relevant changes to the availability or ability to provide the proposed support

Pricing, Payment & Invoices

Prices charged under this Service Agreement are as advised by Camp Kiah and as listed in the Services and Fees guide provided by Camp Kiah.

Camp Kiah will seek payment for the provision of services after the service has been delivered.

Camp Kiah will send you or your representative an invoice for the service we have provided to you. Our preferred method of payment is via EFT and our bank details are provided on the Camp Kiah invoice.

Camp Kiah reserves the right to suspend services until payment is received should or terms of payment be exceeded. Our terms of payment are 14 days from the date of invoice.

By signing this agreement, you agree to be personally responsible for payment of any outstanding amounts payable to Camp Kiah should you have exhausted your NDIS funds.

Cancellation of Booked Services

If you need to cancel a booking, you should do so in line with the Camp Kiah Cancellation Policy, which has been provided as a part of the NDIS Orientation Pack.

Participants Representative*
Date*

DayMonthYear
Signature*

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