Small Group Support Program Registration Form

Small Group Support Program Registration Form

Quick registration for in-service NDIS small group support (4 children per group)
Contact & Child Details
Your Name:

First NameLast Name
Email Address:
example@example.com
Phone Number:
Please enter a valid phone number.
Child's Name:

First NameLast Name
Child's Date of Birth:

MonthDayYear
Date
Are you currently using NDIS funding?

YesNoPending
Service Details
Which kindergarten/preschool/school does your child attend?
Service Address/Suburb:
Educator/Teacher's Name:
Educator/Teacher's Email (please ask them for consent for us to contact them):
Availability
Which days/times work best for your family?

MondayTuesdayWednesdayThursdayFridaySaturday
Which time slot/s generally work best for your child's session?

Morning (9:00 AM – 12:00 PM)Mid-Day (12:00 PM – 3:00 PM)After School (3:30 PM – 6:00 PM)Other
Understanding Shared Support
Please confirm you understand:

I understand this is a small group program with 4 children sharing the $190/hour cost (approximately $47.50 per child per hour)I understand families will need to agree on session times togetherI understand this service is delivered at my child's kindergarten/preschool/schoolI understand Play Move Improve will coordinate with my service and the other families
Consent & What Happens Next
Once you submit this form:

We'll contact you within 2 business days
We'll reach out to your service to discuss logistics
We'll connect families interested in the same service/times
We'll arrange an initial consultation to finalise the group and start dates
Consent:*

I consent to Play Move Improve contacting me about group scheduling, program enrolment, and future workshops.
Should be Empty:

Small Group Support Program Registration Form

Contact & Child Details

Service Details

Availability

Understanding Shared Support

Consent & What Happens Next