Clone of Little Wonderz Summer Holiday

1

Have you signed a service agreement with Wonder Kidz?* This field is required.No: you will receive service agreement to sign

YESNO

2

Partcipant Name* This field is required.

First Name

Last Name

3

Any Changes from the last booking?* This field is required.ex: home address, medications, allergies, behaviours...

YESNO

4

Kindly let us know the changes from the last Booking* This field is required.ex: home address, medications, allergies, behaviours...

5

Primary Carer Name* This field is required.

First Name

Last Name

6

Primary Carer Email* This field is required.

example@example.com

7

Primary Carer Phone Number* This field is required.

Please enter a valid phone number.

8

Date of Birth * This field is required.

Date

9

Gender* This field is required.

Male

Female

Other

10

Is the child considered* This field is required.

An Aboriginal

No

Torres Strait Islander

11

Participant Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

12

School* This field is required.

13

Diagnosis* This field is required.

14

Sensory Preferences (likes, enjoys and calm them down)* This field is required.

15

Sensory Triggers (avoids, dislikes and triggers them)* This field is required.

16

Self feeding* This field is required.

YESNO

17

Self toileting* This field is required.

YESNO

18

Does the participant have NDIS funding* This field is required.

YESNO

19

NDIS Number* This field is required.

20

The plan is* This field is required.

Self-managed

Plan Managed

21

Billing Email* This field is required.

example@example.com

22

Cultural Background* This field is required.

23

Dietary Requirements* This field is required.

25

Kindly upload the latest NDIS funding statement from your plan manager or a screenshot of the participant Support Budget via the NDIS portal /App* This field is required.to make sure they have enough funding

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

26

The Care ratio* This field is required.No Activity fees will be included

1:1 = 95 $/hr

1:2 = 50.0 $/hr

27

Any Behaviours of concerns?* This field is required.IF you choose (YES) , the participant is required to be 1:1

YESNO

28

Behaviours of concerns* This field is required.

Absconding

Self harm

Harming others

others:

29

Any Positive Behaviour Support plan ?* This field is required.

YESNO

30

Any allergies?* This field is required.* If yes, please not we need an medication action plan that is within 12 months of date signed by a medical practioner

YESNO

31

Kindly upload it* This field is required.please not we need an medication action plan that is within 12 months of date signed by a medical practioner

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

32

Allergy cause* This field is required.

33

Allergy signs and symptoms* This field is required.ex: rashes, swelling, sweating..

34

is there any anaphylaxis/allergy plan?* This field is required.please not we need an medication action plan that is within 12 months of date signed by a medical practioner

YESNO

35

Kindly upload the plan* This field is required.please not we need an medication action plan that is within 12 months of date signed by a medical practioner

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

36

Any medications?* This field is required.*If the participant needs to be given medication during the session or in case of emergency

YESNO

37

Medication Name* This field is required.AS Labelled

38

Dosage given:* This field is required.

As prescribed by the doctor

As instructed on the packaging

As needed.

39

By selecting YES, I am giving my consent for the staff at Wonder Kidz to administer medication to the participant as outlined above.* This field is required.

YESNO

40

Transportation?* This field is required.travel time plus 1$ per 1 Km

YESNO

41

By selecting YES, I am giving my consent for the staff at Wonder Kidz to transport the participant in their vehicle.* This field is required.

YESNO

42

Transportation?* This field is required.

Pick Up from home only

Drop Off home only

Both

Parents will transport

43

Billing Out of ?* This field is required.

Core Funding : Social activities

Capacity building: Therapy

44

I acknowledge that the participant will need to bring a snack, a packed lunch, a water bottle, hat and spare clothes that are clearly labelled with their name.* This field is required.

YESNO

45

Responsibility for Fees Not Covered by the NDIS* This field is required.

46

I acknowledge that a CARE plan must be completed prior to attending the program* This field is required.

YESNO

47

Emergency Contact Name* This field is required.other than the parent /Guardian

First Name

Last Name

48

Emergency Contact Phone Number* This field is required.

Please enter a valid phone number.

49

Form filled by:* This field is required.

First Name

Last Name

50

Date* This field is required.

Date