MTL Enrolment Request

Your Name* This field is required.

First Name

Middle Name

Last Name

Please select which describes you best* This field is required.

Name of Young Person (if not same as above)

First Name

Last Name

Date of Birth* This field is required.

Date

Email (Who we should contact to discuss enrolment) * This field is required.

example@example.com

Young person contact (if applicable)

Carer / guardian contact (if applicable)

I am requesting enrolment for (tick all that apply)* This field is required.

Monday 9:30am-3:30pm

Tuesday 9:30am-3:30pm

Wednesday 9:30am-3:30pm

Thursday 9:30am-3:30pm

Friday 9:30am-3:30pm

How does the young person identify?* This field is required.

Female

Male

Non-binary

Prefer not to say

Other

Does the young person identify as ...* This field is required.

Aboriginal

Torres Strait Islander

Prefer not to say

Neither

Is the young person enrolled in school or study, if so what grade?

Is the young person currently employed?

Method of transport to the program (please select one)* This field is required.

Support worker or carer can facilitate transport

Young person can travel independently

Young person would like a referral from us for assistance with their transportation

Other

Help us get to know you! Areas of interest (tick all that apply)* This field is required.

Visual arts, creative learning, craft, colouring in

Video games, tech

Music - listening, writing, playing

Dance, yoga, movement

Exercise, gym, martial arts, sports

Cooking, eating, baking

Gardening, outdoors, nature

Reading, writing

Animals, pets

Movies, t-shows

Other

When would the young person like to begin?* This field is required.

As soon as possible

Within the next 2-4 weeks

Next month

Other

Please select any of below which are relevant for the young person:* This field is required.

Autism

Intellectual (Mild)

Intellectual (Moderate)

Physical

Hearing

Vision

ADHD

OCD

Mental Health

Anxiety

Other

If you would like to tell us more about the interests, challenges or needs of the young person - please do below! If you're a young person applying, please write a short note about you so we can get to know you better!

Does the young person have an approved NDIS plan?* This field is required.

Yes and will be using it for this program

Yes but will not be using it for this program

No, will be privately enrolling

I'm not sure

If you answered yes to the above - is the NDIS plan...If no, please click next

Self-managed

Plan-managed

Other

Does the young person have a support co-ordinator?If not applicable, please click next

Yes (please provide name & contact number below)

I'm not sure

Other

NameIf not applicable please click next

First Name

Last Name

EmailIf not applicable please click next

example@example.com

Phone NumberIf not applicable please click next

Area Code

Phone Number

Anything else we need to know or questions you have, please leave below!

Consult Availability (please select availability for a home or community visit from our support team)* This field is required.