NDIS School Holiday Program Registration Form
Amana Community Services is excited to have you join our Holiday Program. Please complete this registration form, and our team will be in touch within 48 hours to confirm your booking.
Confidentiality Disclaimer:
All information collected in this registration form is strictly confidential and will only be used for the purpose of delivering and supporting participation in the NDIS School Holiday Program. Your details will not be shared with any third party without your consent, except where required by law.
Are you completing this registration form for yourself or on behalf of someone else:
*
For Myself
On Behalf of Someone
Participant Details:
Full Name
*
First Name
Last Name
Parent/ Guardian Name:
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
NDIS Number
*
Management Type:
*
Plan Managed
Self Managed
Agency Managed
NDIS Plan Start Date:
*
-
Month
-
Day
Year
Date
NDIS Plan End Date:
*
-
Month
-
Day
Year
Date
Support Coordinator (if applicable)
Full Name:
Phone or Email:
Emergency Contact Details
*
Rows
Full Name
Contact Number
Primary Contact
Secondary Contact
Contact Details for Invoices (if applicable)
Full Name:
Email:
Mode of Communication:
*
Language Spoken:
Preferred Method of Communication:
Please Select
Face to Face
Phone Call
Text Message
Email
Letter
Medical Details:
Briefly describe the participant's condition or support needs:
*
Level of Independence for Activities of Daily Living:
*
Current GP:
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Allergies:
*
Dietary Requirements:
*
Medications:
*
Back
Next
Program Detail:
How many days would you like to attend?
*
Monday (Board Games & Nerf War)
Tuesday (Movie Making Competition)
Wednesday (Movie Making Competition)
Thursday (Card Games, Legos & Water Fight)
Friday (Bowling, Laser Tag & Arcade)
Do you require transport services?
*
Yes
No
Additional Notes/ Queries:
Participant/ Guardian Signature:
*
Date
*
-
Month
-
Day
Year
Continue
Continue
Should be Empty: