Weekend Program Registration Form Perth
Register for our upcoming Term 3 Weekend Programs!
26th July 2025 - 28th September 2025
Participant Details
Participant's Full Name:
*
First Name
Last Name
{participantsFull:first}'s Date of Birth
*
/
Day
/
Month
Year
Date
Is {participantsFull:first} currently registered with Sparkle Centre?
*
Yes
No
Have {participantsFull:first}'s details changed?
*
Yes
No
{participantsFull:first}'s NDIS Number:
Please enter Participant's NDIS number
{participantsFull:first}'s Address:
Street Address
Street Address Line 2
Suburb
State
Postcode
Emergency Contact 1 Details
Emergency Contact Name:
*
First Name
Last Name
Relationship to {participantsFull:first}:
*
Emergency Contact Number:
*
Format: 0400 000 000.
Emergency Contact Email Address:
*
Emergency Contact 2 Details
Emergency Contact Name:
First Name
Last Name
Relationship to {participantsFull:first}
Emergency Contact Number
Format: 0400 000 000.
Emergency Contact Email Address:
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Weekend Program Booking
Which Weekend Programs would you like to book in for?
*
Please list any dietary requirements and/or allergies:
Leave blank if not applicable
Is there anything else you would like to include?
Leave blank if not applicable
Does the {participantsFull:first} hold a current NSW Companion Card?
*
Yes
No
Participant’s Companion Card:
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*
Signature
*
Full name of the person completing form:
*
First Name
Last Name
Date
*
-
Day
-
Month
Year
Date
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