Holiday Program Registration

Holiday Program Registration

Fill out the form carefully for registration
Participant Name

First NameMiddle NameLast Name
Date of birth

MonthDayYear
Date
Collect/Drop Off Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender
Participant NDIS Number
Please enter a valid participants NDIS number.
Phone Number
Please enter a valid phone number.
E-mail
example@example.com

Emergency Contact Details
Emergency Contact Name

First NameLast Name
Relationship to participant

MotherFatherCareerOther
Phone Number
Please enter a valid phone number.
Email
example@example.com

Ability and Ambition – Travel Consent Form Empowering Your NDIS Journey
Purpose of Consent

This form provides permission for Ability and Ambition staff to transport the participant during supports, community access, activities, and Holiday Program events. Transport may occur in:

Ability and Ambition vehicles
Staff personal vehicles (when authorised)

This consent ensures the participant is safely transported according to NDIS Practice Standards and Ability and Ambition policies.

By signing this form, you consent to the participant being transported to and from:

Scheduled community access supports:

Holiday Program activities

Educational, recreational and skill-building outings

Local and out-of-town locations including (but not limited to):
Swan Hill, Echuca Moama, Lake Boga, Shepparton, Kyneton, Tooleybuc, Halls Gap, and surrounding areas.

Transport may include:
Pick-up from home
Drop-off at home
Group transport
Individual transport
Safety Considerations Ability and Ambition staff will ensure: All vehicles are roadworthy and insured Seatbelts or appropriate restraints are used at all times Child/booster seats are used when required Participants are supervised appropriately Staff follow Ability and Ambition’s Transport Safety Policy Staff comply with NDIS Worker Screening and Code of Conduct Please list any relevant safety, behavioural, medical, or sensory considerations:
Permission for Out-of-Town Travel I understand that some programs or activities may require travel outside of Swan Hill and surrounding towns. This may include long-distance day trips. (Staff will only schedule supports according to the option selected.)

I give permission for out-of-town travelI do NOT give permission for out-of-town travel
Declaration & Signature I confirm that I am the participant, I have read and understood this Travel Consent Form and give my permission for Ability and Ambition to provide transport as outlined.

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Date

MonthDayYear
Date
Declaration & Signature I confirm that I am the authorised guardian/decision-maker. I have read and understood this Travel Consent Form and give my permission for Ability and Ambition to provide transport as outlined.

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Date

MonthDayYear
Date

Ability and Ambition – Media Consent Form Empowering Your NDIS Journey
Purpose of Consent
This form seeks your permission to use your image, video, audio, or other media content for promotional and marketing purposes. This may include, but is not limited to:

Social media platforms (e.g., Facebook, Instagram)

Ability and Ambition website

Newsletters and brochures

Promotional videos and advertisements

Your consent is voluntary, and you have the right to withdraw it at any time.
Withdrawal of Consent
You have the right to withdraw your consent at any time. To do so, please contact us at:

Phone: 0475 970 387

Email: admin@abilityandambition.com

Postal Address: 378 Campbell St, Swan Hill VIC 3585

Upon withdrawal, we will cease using your media content as per your instructions.
Media Consent

Yes, I consent to the use of my media content for promotional and marketing purposes.No, I do not consent to the use of my media content.
If you have any specific limitations or conditions regarding the use of your media content, please detail them below:
Participant Acknowledgment and Signature By signing below, you acknowledge that you have read and understood the contents of this consent form and agree to the use of your media content as specified above.

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Participant Acknowledgment and Signature Date

MonthDayYear
Date
Participants Career/Representative Acknowledgment and Signature By signing below, you acknowledge that you have read and understood the contents of this consent form and agree to the use of your media content as specified above.

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Participants Career/Representative Acknowledgment and Signature Date

MonthDayYear
Date

Confidential Medical Information & Indemnity Waiver Form
Medical Indemnity: Participants and/or their families are responsible for all medical costs if a
Participant is injured on an Ability&Ambition Pty Ltd trip away and in signing this form,
Participants and/or their families indemnify Ability&Ambition Pty Ltd for any accident, illness or
injury sustained by the Participant.
Parent/Guardian/Child Nominee
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Emergency/Next of Kin
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Medicare Details
Medicare

Medicare NumberReference Number
Private Health (Optional)
Private Health Details

ProviderMember Number
Ambulance VIC Member (Optional)
Member Number
Medical Conditions
Description of Medical Conditions
Please include required management plans (Anaphylaxis, Epilepsy etc)
Medication Details
Description of medications including dosages and times of administration (Participants responsibility)
Please note A&A staff are not trained in Medication administration and as such it will be the responsibility of the Participant to administer their own medication.
Allergy Details
Description of allergies & specialist care required
Please note allergy management plans are required. Up to date plans need to be forwarded to admin@abilityandambition.com
If there is a situation or incident which requires first aid to be administered to the Participant,
Ability&Ambition Pty Ltd staff will administer first aid that is reasonably necessary and
appropriate to their level of training. Ability&Ambition Pty Ltd staff will also seek emergency
medical attention for the Participant if it is considered reasonably necessary. In the event that
the Participant needs medical attention during the activity, Ability&Ambition Pty Ltd staff will
contact you as soon as practically possible.
Participant Acknowledgment and Signature

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Date

MonthDayYear
Date
Participants Career/Representative Acknowledgment and Signature

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Date

MonthDayYear
Date

Ability and Ambition PTY LTD Holiday Program Liability Waiver and Release ACN 656 177 856
Activity/Program: Ability & Ambition Holiday Program
Location(s): Various community, outdoor, indoor, and out-of-town activity locations as scheduled by the Provider.
Participants Name

First NameLast Name
Waiver and Release Of Liability
I, Participant & Guardian, HEREBY WAIVE, RELEASE, indemnify, hold harmless, and forever discharge Ability & Ambition Pty Ltd, including its officers, directors, employees, contractors, volunteers, and affiliates (“Provider”), from any and all claims, demands, actions, causes of action, damages, losses, liabilities, or expenses arising out of or related to my (or my child’s) participation in the Ability & Ambition Holiday Program, including all associated travel and activities.
Acknowledgement Of Risk
I acknowledge that participation in the Holiday Program involves inherent risks, including but not limited to:

Travel in vehicles (local and out-of-town)
Outdoor environments, uneven ground, weather exposure
Water-based activities (swimming, Aqua Island, paddle boarding, boating)
Use of recreational equipment (bikes, fishing rods, sports gear, etc.)
Physical activities (walking, hiking, sports, climbing, stretching, yoga)
Crowded environments, public spaces, busy venues
Heat, cold, sun exposure, insects, and environmental hazards
Food consumption risks (allergic reactions, choking, contamination)
Slips, trips, falls, strains, sprains, or other injuries
Interactions with other participants, staff, or members of the public
I voluntarily assume all such risks.
Voluntary Participation
I confirm that participation in these activities is voluntary and that I (or my child) am/is physically and mentally capable of taking part in the scheduled activities. I acknowledge that it is my responsibility to notify the Provider of any relevant medical, behavioural, or health concerns prior to participation.
Medical Authorisation
In the event of illness, accident, or injury, I authorise Provider staff to:

Administer First Aid
Contact emergency medical services
Provide relevant participant information to medical personnel
Act in the best interest of the Participant to ensure safety
I agree that all associated medical or ambulance costs are the responsibility of the Client/Guardian.
Expected Conduct & Safety Compliance
I agree to follow all safety instructions provided by Provider staff, including rules regarding:

Travel safety
Water safety
Behaviour and conduct
Equipment use
General group supervision
I understand that unsafe, aggressive, or inappropriate behaviour may result in removal from the activity or program at the discretion of the Provider.
Personal Property
I acknowledge that the Provider is not responsible for any lost, damaged, or stolen belongings brought to activities or during travel.
Complete Agreement
This WAIVER AND RELEASE constitutes the full and complete agreement between the parties and supersedes any prior written or verbal agreements. This waiver remains effective for all scheduled Holiday Program activities unless revoked in writing.
Legal Understanding
I acknowledge that by signing this form:

I understand its legal effect
I am waiving certain legal rights and claims
I agree that Ability & Ambition Pty Ltd is not liable for injuries, losses, or damages except in cases of proven negligence or intentional misconduct
I sign this document freely, voluntarily, and without coercion.
Participant Acknowledgment and Signature

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Date

MonthDayYear
Date
Participants Career/Representative Acknowledgment and Signature

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Date

MonthDayYear
Date
Should be Empty:

Holiday Program Registration

Emergency Contact Details

Transport Information

Ability and Ambition – Travel Consent Form Empowering Your NDIS Journey

Ability and Ambition – Media Consent Form Empowering Your NDIS Journey

Purpose of Consent

Withdrawal of Consent

Confidential Medical Information & Indemnity Waiver Form

Parent/Guardian/Child Nominee

Emergency/Next of Kin

Medicare Details

Private Health (Optional)

Ambulance VIC Member (Optional)

Medical Conditions

Medication Details

Allergy Details

Ability and Ambition PTY LTD Holiday Program Liability Waiver and Release ACN 656 177 856

Waiver and Release Of Liability

Acknowledgement Of Risk

Voluntary Participation

Medical Authorisation

Expected Conduct & Safety Compliance

Personal Property

Complete Agreement

Legal Understanding