Excursions - SERVICE AGREEMENT & SCHEDULE OF SUPPORTS

Excursions - SERVICE AGREEMENT & SCHEDULE OF SUPPORTS
Agreement Date*

MonthDayYear
Date
Participant Details:
Participant Details*

First NameLast Name
Fullname*

First NameLast Name
Date Of Birth*

DayMonthYear
Date
NDIS Number *
NDIS Plan Dates (Annually or Quarter 1)*
NDIS Plan Dates (Annually or Quarter 1)*

Start DateEnd Date
NDIS Plan Dates (Quarter 2)

Start DateEnd Date
NDIS Plan Dates (Quarter 3)

Start DateEnd Date
NDIS Plan Dates (Quarter 4)

Start DateEnd Date
Participant's Representative # 1 (Parent/Carer)*

First NameLast Name
Relationship to Participant*
Date

MonthDayYear
Date
Participant's Representative (Parent/Carer) Email*
example@example.com
Participant's Representative (Parent/Carer) Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
How is your NDIS funding for WRTS Services Managed:*

Self ManagedPlan ManagedNDIA ManagedOther
Plan Management Company Name (if relevant):
Plan Management Email Address to send Invoices to:
Plan Management Phone Number:
Support Coordinator / LAC Details (if relevant):
My Funding Categories :*

CORE - Group Activity - 04_102_0136_6_1CORE - Access Community Social and Rec Activity - Standard - 04_104_0125_6_1CORE - Community Social And Recreational Activities - 04_210_0125_6_1CAPACITY BUILDING – Supports Other - Skills Development & Training - 15_037_0117_1_3CAPACITY BUILDING - Development of Daily Living and Life Skill - Innovative Community Participation - 09_008_0116_6_3CAPACITY BUILDING– Development of Daily Living and Life Skill - Increased Social and Community Participation - 09_006_0106_6_3CAPACITY BUILDING –Community Participation Activities - Skills Development & Training - 09_009_0117_6_3CAPACITY BUILDING – Increased Social and Community Participation - 09_006_0106_6_3CAPACITY BUILDING –Community Participation Activities - Skills Development & Training - 09_009_0117_6_3
Please tick the level of support your child requires at the Kids Gym*

One Staff Member to One Child Ratio (1:1 Support)One Staff Member to Two Child Ratio (1:2 Support)One Staff Member to Three Child Ratio (1:3 Support) Excursions
Select Excursions you are registering for (you can select multiple) - all excursions start at WRTS Somerville :*

Saturday 21 February Moonlit Sanctuary OP$35Saturday 21 March Enchanted Maze Entry Only OP $40Saturday 21 March Enchanted Maze & Tree Surfing OP $100Saturday 30 May Puffing Billy OP $44 *2pm finishSaturday 27 June Sk8house OP $25Saturday 22 August The Ranch Pony Rides OP $32Saturday 17 October Yarra Valley Chocolaterie OP $45 TBC * 2pm finishSaturday 14 November Deep Creek Eco Playground OP $Nil
Has this child attended a WRTS Somerville Session before?*

YesNO (If not, we will be in touch to arrange an induction session)
Child Two (2) Name

First NameLast Name
Child Two (2) Date Of Birth

DayMonthYear
Date
Please tick the level of support your child requires at the Kids Gym

One Staff Member to One Child Ratio (1:1 Support)One Staff Member to Two Child Ratio (1:2 Support)One Staff Member to Three Child Ratio (1:3 Support)
Has this child attended a WRTS Somerville Group/Holiday Session before?*

YesNO (If not, we will be in touch to arrange an induction session)
Please tick any day you are interested in your child attending:

Friday Rockin' Friends 5pm-8pm IN GYM
Please indicate frequency:

FortnightlyAd-hoc - dates to be confirmed
Please tick any day you are interested in your child attending:

Sunday Rockin' Friends 9am - 12pm IN GYM
Please indicate frequency:

WeeklyFortnightlyAd-hoc - dates to be confirmed
Please tick any day you are interested in your child attending:

Saturday Rockin' Friends 9am - 12pm EXCURSION TBCSaturday Rockin' Friends 9am - 12pm EXCURSION TBC
Please indicate frequency:

MonthlyAd-hoc - dates to be confirmed
COMPANION CARD: If your child has a Companion Card, please upload a photo of the card here. To apply for a Companion Card visit https://www.companioncard.vic.gov.au/how-apply*

YESNO
Upload a copy of your Companion Card (if applicable)

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MEDICATION My child(ren) will require Medication to be administered by WRTS SOMERVILLE during Rockin' Friends Sessions:
Does your child suffer from any known allergies?*

YESNO
DIETARY REQUIREMENTS & ALLERGIES Some activities have a food element to them. Does your child have any allergies/intolerances? If so, please provide details.
If YES then please describe Allergy, Reaction and treatment (note if your child is Anaphylaxis we will require a Medical Management Plan and the Epi-pen will need to be brought to each session)
Please list interest or things your child likes doing
Please list things that motivate or ways your child might be encouraged to participate
Is your child toilet trained? Details if required.*
What is your child's preferred model of communication?
Does your child have physical limitations we should be aware of?*
Are they any behaviour or safety concerns that we should be aware of to help your child have a great time?
Upload a copy of your child's Behaviour Support Plan

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Do you have any concerns about your child absconding from the Gym or during excursions?*

YESNO
Has this happened before when your child was with you or in the care of others? If Yes please provide details.*

YESNO
If Yes please provide details:
I have reviewed the program of activities of WRTS and feel that my child can participate with the following restrictions/adaptions/supports.
BEHAVIOUR CONCERNS: I understand that WRTS Management reserves the right to terminate services at any time due to behaviour concerns that may adversely impact the other children and staff of WRTS. I will be advised verbally and in writing.*

YES
EXCURSIONS : I am aware that WRTS Management may determine that it is NOT appropriate for my child to attend Excursions away from the Gym. This decision will be made based on observations of my child as they participate in the program. If my child cannot attend the excursion I understand that I will have the choice to (a) cancel care for that day (at no cost) or (b) have my child at the Gym and that fees will be charged based on the staff:child ratio remaining at the gym (this may mean that my fees are for 1:1 support on this day/s) or (c) attend the excursion with my child*

YES
MEDIA CONSENT We occasionally post photos from the day on our Instagram and Facebook page to show the daily activities. No names are listed. Are you ok for your child’s image to be posted?*

YESNO
NDIS GROUP PRICING GUIDELINE I understand that NDIS Pricing Guidelines require WRTS to outline our costs in our invoicing and separate out fees for Support hours, Gym Capital Costs, Non Face to Face Planning time and Travel Costs (where required). These line items will be outlined in our Group Invoices. These changes have in some cases altered the prices slightly. LACs, Plan Managers and Support Coords will be expecting these changes.*

I understand this Pricing Guidline
OUT-OF-POCKET ACTIVITY FEE. I understand that all Community Excursions incur an out-of-pocket fee to cover excursion activities and costs that the NDIS do not cover eg. tickets, supplies. Each Excursion Out of Pocket Fee will now vary. The Out of Pocket fee for each day is indicated with a colour code on the program's flyer. This will be invoiced for separately and must be paid personally, not through funding, in a timely manner. The Out of Pocket Fee adheres to the same cancellation policy as above.*

Yes, I understand and accept
CANCELLATION POLICY: I am aware of and agree to adhere to WRTS Australia's Cancellation Policy, as outlined below and agree to adhere to its terms.*

Cancellations more than 48 hours before the Service – Full Refund/No ChargeCancellations within 48 hours - 0% Refund/Full Payment (if participant's session can not be filled by another participant)NO SHOW - 0% Refund/Full PaymentWRTS’s Accounts Receivable Team will follow up any non payments in line with NDIS Policy and non payments will be reported to the NDIA.Client can elect to have left as a credit on a client’s account for future services. Refunds or Credit can not be used for Rock Shop Products

FEES/CHARGES

Fees for 2026 Program (from 1 January 2026)* are as follows and are based on the level of support your child requires:

3 Hours

	Weekday	Saturday	Sunday
1:4 Support	$113.63	$135.08	$156.53
1:3 Support	$131.18	$159.78	$188.38
1:2 Support	$166.30	$209.20	$252.10
1:1 Support	$271.64	$357.44	$443.24

5 Hours (Excursions)

	Saturday
1:4 Support	$190.01
1:3 Support	$231.19
1:2 Support	$313.55
1:1 Support	$560.62

NOTE:

Excursion fees will vary as $1 per KM travel fee is added

Excursion Out of Pocket (OP) Fees apply for costs not covered by NDIS such as Entrance Fees to venues/events.

Price increases will be in line with updates to the NDIS Pricing Guide

In consideration of being permitted by We Rock the Spectrum Kid’s Gym (hereinafter “WRTS”) to participate in its activities and to use its equipmentand facilities, now and in the future, I as parent or legal guardian of the child/ren [named at the bottom of this document] a minor (hereinafter “Minor”),hereby grant the permission necessary to allow Minor to participate in all activities at this WRTS location and agree with all the terms of this Releaseof Liability, Indemnity Agreement, and Assumption of Risk Agreement (hereinafter “Agreement”). I, in my own behalf and on behalf of Minor,further agree to release, indemnify and discharge WRTS, its agents, owners, shareholders, directors, partners, employees, volunteers,manufacturers, participants, lessors, affiliates, its subsidiaries, related and affiliated entities, successors and assigns (hereinafter “Released Parties”),on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and estate as follows:*

I understand and acknowledge that the activity the Minor is about to voluntarily engage in as a participant bears certain known risks and unanticipated risks which could result in physical, emotional, or mental injury, paralysis, illness or disease, death, or damage to Minor, to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activities at WRTS. The risks include, among other things: Use of WRTS equipment entail certain risks that simply cannot be eliminated without jeopardizing the essential qualities of the activity. Use of equipment may expose participants to the usual risk of cuts, scrapes, bruises, and rug burns. Other more serious risks exist as well. Participants may fall off equipment, sprain, injure, or break fingers, toes, wrists, feet, legs, back, or neck, and can suffer more serious bodily injuries as well. In any event, if Minor is injured and may require medical assistance, you as parent or legal guardian will assume full liability and responsibility for the expenses.Furthermore, WRTS employees have difficult jobs to perform. They seek safety, but they are not infallible. They might be unaware of a participant’s fitness or abilities. They may give incomplete warnings or instructions, and the equipment being used might become loose, out of adjustment, or malfunction. There is also a risk that WRTS employees may be negligent in, among other things, monitoring and supervising use of its equipment and facilities and in the maintenance and repair of its equipment and facilities.I agree that this Release of Liability, Indemnity Agreement, and Assumption of Risk Agreement is made on behalf of that Minor participant and that all of the releases, waivers and promises herein are binding on that Minor participant. I represent that I have full authority as Parent or Legal Guardian of the minor participant to bind the Minor participant to this Agreement.I expressly agree and promise to accept and assume all of the risks existing in this activity on behalf of Minor. The Minor’s participation in this activity is purely voluntary, and I elect to have Minor participate in spite of all the risks.I hereby voluntarily release, forever discharge, and agree to defend, indemnify and hold harmless WRTS and all Released Parties from any and all claims, demands, or causes of action, which are in any way connected with Minor’s participation in this activity or use of WRTS equipment or facilities, including any such claims which allege negligent acts or omissions of Released Parties.I indemnify and save and hold harmless WRTS and the Released Parties against any loss, liability, damage or cost that may incur arising out of or in any way connected with the Minor’s use of WRTS equipment or gear provided therewith or any acts or omissions of the Released Parties.Should WRTS or anyone acting on its behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs. This means that I will pay all of those attorney’s fees and costs myself.I certify that I have adequate insurance to cover any injury or damage that Minor may cause or suffer while participating in all WRTS activities, or else I agree to bear the costs of such injury or damage to Minor myself. I further certify that I am willing to assume the risk of any medical or physical condition that Minor may have.I expressly agree that this Agreement is governed by the State of Victoria, Australia and is intended to be as broad and inclusive as permitted by Victorian and Australian law, and that in the event any portion of this Agreement is determined to be invalid, illegal, or unenforceable, the validity, legality and enforceability of the balance of the Agreement shall not be affected or impaired in any way and shall continue in full legal force and effect. In the event that I file a lawsuit against WRTS, I agree to do so solely in the State of Victoria, Australia and I further agree that the substantive law of the State of Victoria, Australia shall apply in that action without regard to the conflict of the law rules of that state.I further agree to defend, indemnify and hold harmless WRTS from any and all claims or lawsuits for personal injury, property damage or otherwise which are brought by, or on behalf of the Minor, and which are in any way connected with such use or participation by the Minor, including injuries or damages caused by the negligence of Released Parties, except injuries or damages caused by the sole negligence or wilful misconduct of the party seeking indemnity.I certify that, to the best of my knowledge, the Minor does not have a health condition that would make it inadvisable for the Minor to participate in WRTS activities.I agree to grant WRTS and all Related Parties, the irrevocable right and permission to photograph and/or record me or Minor in connection with WRTS to use the photograph and/or recording for all purposes, including advertising and promotional purposes, in any manner in any and all media now or hereafter known, in perpetuity throughout the world, without restriction as to alteration. I waive any right to inspect or approve the use of the photograph and/or recording and acknowledge and agree that the rights granted to this release are without compensation of any kind. All photographs and/or recordings are exclusive to WRTS.In consideration of not being required to sign a fresh copy of this Agreement before each visit, I further agree that this Agreement shall apply to all future visits of the Minor to this WRTS location.By signing this Agreement, I acknowledge that I have had sufficient opportunity to read this entire Agreement, I understand it completely, I understand that it affects my legal rights, and I agree to be bound by its terms. I also agree if anyone is hurt or property damaged during the Minor’s participation in this activity, I may be found by a court of law to have waived my or the Minor participant’s right to maintain a lawsuit against WRTS and the Released Parties on the basis of any claim from which I have released them herein.By signing this agreement, you are acknowledging that We Rock the Spectrum Kids Gym is not a licensed Child Care.
By Signing this I agree to all Booking Conditions stated above: (PLEASE ENSURE YOU PRESS SUBMIT WHEN FINISHED)*
Date*

DayMonthYear
Date
This Service Agreement is made between:(A participant in the National Disability Insurance Scheme (NDIS Participant)
and We Rock the Spectrum Somerville on Date:

MonthDayYear
Date
The NDIS and this Service Agreement
This Service Agreement is made for the purpose of providing supports under the NDIS Participant’s NDIS plan.
The parties agree that this Service Agreement is made in the context of the NDIS, which is a scheme that aims to:
• support the independence and social and economic participation of people with disability and
• enable people with a disability to exercise choice and control in the pursuit of their goals and the planning and delivery of their supports.  
WE ROCK THE SPECTRUM SOMERVILLES' (WRTS) RESPONSIBILITIES

WRTS or her representatives agrees to:  
•       review the provision of supports at least annually with the NDIS Participant
•       once agreed, provide supports that meet the NDIS Participant’s needs at the NDIS Participant’s preferred times
•       communicate openly and honestly in a timely manner 
•       treat the NDIS Participant with courtesy and respect
•       consult the NDIS Participant on decisions about how supports are provided 
•       give the NDIS Participant information about managing any complaints or disagreements and details of WRTS or WRTS representatives cancellation policy 
•       listen to the NDIS Participant’s feedback and resolve problems quickly 
•       give the NDIS Participant a minimum of 24 Hours notice if WRTS or her representativesneeds to change a scheduled appointment to provide supports 
•       give the NDIS Participant the required notice if WRTS needs to end this Service Agreement(see ‘Ending this Service Agreement’ below for more information)
•       protect the NDIS Participant’s privacy and confidential information 
•       provide supports in a manner consistent with all relevant laws, including the NDIS Act 2013 and Rules, and the Australian Consumer Law
•       keep accurate records on the supports provided to the NDIS Participant and 
•       issue regular invoices and statements of the supports delivered to the NDIS Participant.

RESPONSIBILITIES OF THE NDIS PARTICIPANT / NDIS PARTICIPANT'S RESPRESENTATIVE 

The NDIS Participant / NDIS Participant’s representative agrees to:
•       inform WRTS or WRTS representatives about how they wish the supports to be delivered to meet the NDIS Participant’s needs 
•       treat WRTS or WRTS representatives workers with courtesy and respect 
•       talk to WRTS or WRTS representatives if the NDIS Participant has any concerns about the supports being provided
•       give WRTS or representatives the minimum required notice if the NDIS Participant cannot make a scheduled appointment, noting that if the notice is not provided by then, WRTS or representatives cancellation policy will apply (see ‘Cancellation Policy’)
•       give WRTS or WRTS representatives the required notice if the NDIS Participant needs to end this Service Agreement (see ‘Ending this Service Agreement’ below for more information) and  
•       let WRTS or WRTS representatives know immediately if the NDIS Participant’s NDIS plan is suspended or replaced by a new NDIS plan, or the NDIS Participant stops being a participant in the NDIS.

PAYMENTS
WRTS or WRTS representatives will seek payment for their provision of supports after the supports have been delivered.
Invoicing will be determined by how the participant’s Funding with WRTS or hWRTSr representatives is managed.

SELF MANAGED:
When the NDIS Participant has chosen to self-manage the funding for NDIS supports provided under this Service Agreement, the following will take place. After providing those supports, WRTS or WRTS representatives will send the NDIS Participant an invoice for those supports for the NDIS Participant to pay. The NDIS Participant will pay the invoice by direct debit / cash / EFT within 7 Days.

SELF MANAGED PLAN NOMINEE
When the NDIS Participant’s Nominee manages the funding for supports provided under this Service Agreement, the following will take place. After providing those supports, WRTS or WRTS representatives will send the NDIS Participant’s Nominee an invoice for those supports for the NDIS Participant’s Nominee to pay. The NDIS Participant’s Nominee will pay the invoice by direct debit / cash / EFT within 7 Days.

NDIA (AGENCY) MANAGED
When the NDIS Participant has nominated the NDIA to manage the funding for supports provided under this Service Agreement, the following will take place. After providing those supports, WRTS or WRTS representatives will claim payment for those supports from the NDIA.

PLAN MANAGED
When NDIS Participant has nominated a Plan Management Provider (listed above if applicable) to manage the funding for NDIS supports provided under this Service Agreement, the following will take place. After providing those supports, WRTS or WRTS representatives will claim payment for those supports from the nominated Plan Management Company. The Participant/Participant’s Representative will be copied in to the invoice email.

CHANGES TO THIS SERVICE AGREEMENT   If changes to the supports or their delivery are required, the parties agree to discuss and review this Service Agreement. The parties agree that any changes to this Service Agreement will be in writing, signed and dated by the parties.

ENDING OF THIS SERVICE AGGREEMENT
Should either party wish to end this Service Agreement they must give 1 month’s notice. If either party seriously breaches this Service Agreement the requirement of notice will be waived.

FEEDBACK & COMPLAINTS

If the NDIS Participant (or any other person) wishes to give WRTS feedback or make a complaint, they can do so by:
·       speaking directly with a WRTS or WRTS representatives or giving a deatials via email or in writing.
·       emailing info@werockthespectrumsomerville.com.au or
·       phoning (03) 5977 6936
·       writing to 3/36 Guelph Street Somerville VIC 3912 or

If the person does not want to make a complaint directly to WRTS, or they are not happy with how WRTS has responded to their complaint, they can complain to the NDIS Quality and Safeguards Commission (NDIS Commission).

Complaints to the NDIS Commission can be lodged:
·       Phone: 1800 035 544
o   Phone hours services are currently available Monday to Friday (excluding public holidays) between 9am – 5pm for all States and Territories (except for the Northern Territory, available until 4:30pm)
·       Online: Complaint Contact Form

More information is available via the ‘How to make a complaint about a provider’ webpage via the NDIS Commission’s website.

Complaints can also be made to:

The Disability Services Commissioner: 1800 677 342
Office of the Public Advocate: 1300 309 337
Health Complaints Commissioner: 1300 582 113
Victorian Equal Opportunity & Human Rights Commission: 1300 292 153
Victorian Ombudsman: 03 9613 6222
Human Rights Commission: 1300 656 419
Australian Department of Education and Training: 1300 566 046
Victorian Department of Education and Training: 1800 809 834

Where required, WRTS representative will assist people making a complaint, or people with disability affected by a complaint, to contact the NDIS Commission or other complaints body.

WRTS representative will also support people making or impacted by a complaint to contact an advocate (if they wish to do so) to support them through the feedback and complaints process.

Complaints will be formally acknowledged within 2 Working days. All complaints will be responded to as quickly as possible, and within 14 Days from acknowledgement. If a complaint cannot be responded to in full within 14 Days of acknowledgement, the complainant will be provided with an update, including when a full response can be expected.

All feedback and complaints will be used by WRTS and her representatives to continuously improve service delivery.

Conflicts of Interest
Any perceived or actual conflicts of interest associated with PAULINE SMALES or her representative service delivery will be managed in accordance with its Conflict of Interest Policy and Procedure.

Emergency and Disaster Management
WRTS and her representative are committed to providing support to NDIS Participants without interruption throughout the period of their Service Agreement. This includes in the event of an emergency or disaster.

Where changes or interruptions are unavoidable, alternative arrangements will be explained and agreed with the NDIS Participant, with a key focus on minimising the impact to the NDIS Participant.

WRTS and WRTS representative will ensure that any alternative supports enacted in the event of an emergency or disaster are delivered in a way that is appropriate to the NDIS Participant’s needs, preferences, and goals.

Continuity of Support
WRTSS and her representative ensures the business operates with a sufficient amount of qualified staff to support its participants. In the event that the participant’s support staff is unavailable, WRTS or WRTS representative will provide an alternative support staff member of equal or greater qualification. The replacement staff member will be given ample time to be briefed by management and have access to the participant’s Support Plan and Risk Assessment documents and any additional relevant health and behavioural plan information.
Participants will be informed of any staff changes within 24 hours before the service, where possible.

WRTS or WRTS representatives will ensure that any alternative supports are delivered in a way that is appropriate to the NDIS Participant’s needs, preferences, and goals.

Goods and Services Tax (GST)
For the purposes of GST legislation, the Parties confirm that:
•       a supply of supports under this Service Agreement is a supply of one or more of the reasonable and necessary supports specified in the statement included, under subsection 33(2) of the NDIS Act, in the NDIS Participant’s NDIS Plan currently in effect under section 37 of the NDIS Act
•       the NDIS Participant’s NDIS Plan is expected to remain in effect during the period the supports are provided and  
•       the [NDIS Participant / NDIS Participant’s representative] will immediately notify the provider if the NDIS Participant’s NDIS Plan is replaced by a new plan or the NDIS Participant stops being a participant in the NDIS.  

Cancellation Policy
In the event of a short-notice cancellation (or no show), WRTS or WRTS representatives can claim 100% of the agreed fee associated with the activity from the NDIS Participant’s plan, subject to the NDIS Pricing Arrangements and Price Limits in effect at the time, and the terms of this Service Agreement.

A cancellation is a short notice cancellation if the participant:
•       does not show up for a scheduled support within a reasonable time, or is not present at the agreed place and within a reasonable time when WRTS or WRTS representative are leaving to travel to an excursion destination
•       has given less than two (2) clear business days’ notice for a support that meets both of the following conditions:
•       the support is less than 8 hours continuous duration AND
•       the agreed total price for the support is less than $1000

WRTS or WRTS representative can only claim from the participant’s plan for a Short Notice Cancellation of the delivery of a support item to the participant if all of the following conditions are met:
•       the NDIS Pricing Arrangements and Price Limits guide indicates that providers can claim for Short Notice Cancellations in respect of that support item
•       the proposed charges for the activities comply with the NDIS Pricing Arrangements and Price Limits guide
• WRTS or WRTS representative has the agreement of the participant in advance (that is, this Service Agreement specifies that Short Notice Cancellations can be claimed) and
• WRTSS or WRTS representative was not able to find alternative billable work for the relevant worker and is required to pay the worker for the time that would have been spent providing the support.

WRTS or WRTS representative cancels a support due to operational reasons, the service will be rescheduled at no penalty to either party.
WRTS will work closely with other agencies to coordinate the best support for the NDIS Participant. This means the NDIS Participant’s informed consent for the sharing of information will be sought and respected in all situations unless:

1. WRTS is obliged by law to disclose the NDIS Participant’s information regardless of consent or otherwise.

2. It is unreasonable or impracticable to gain consent or consent has been refused and:

3.The disclosure is reasonably necessary to prevent or lessen a serious threat to the life, health or safety of a person or group of people.
NDIS Participant / NDIS Participant’s Representative Consent  
I, the Participant/Participant's Representative hereby acknowledges that WRTS has advised me of the following:*

WRTS Privacy and Confidentiality Policy and Procedure [or equivalent] my right to access my personal information and my right to withdraw my consent at any time.I understand that the following service(s) are recommended and relevant information about me may be forwarded to the agency(s) that provides these services, in order that I receive the best possible service:I understand that WRTS may need to collaborate with other providers, including health care and allied health providers, to share my information, manage risks to me, and meet my needs.I understand WRTS must comply with relevant privacy laws and I will contact the organisation immediately if I feel that these laws have been breached.My worker has discussed with me how and why certain information about me may need to be provided to other service providers.
I, the Participant/Participant's Representative hereby acknowledges that WRTS has advised me of the following:*

I understand the recommendations and I give my permission for the information to be shared with the people or agencies as detailed above. ORI do not give my consent for WRTS to collect and disclose my personal information to any third parties.
I, the Participant/Participant's Representative hereby acknowledge:*

I consent to photographs, videos and/or recordings being taken by We Rock the Spectrum Australia. ORI do not consent to photographs, videos and/or recordings being taken by We Rock the Spectrum Australia.
Signature of NDIS Participant / NDIS Participant’s representative*
Name*

First NameLast Name
Date*

MonthDayYear
Date
VERBAL CONSENT

Verbal consent should only be used where it is not practicable to obtain written consent. I have discussed the proposed referrals with the participant or authorized representative and I am satisfied that they understand the proposed uses and disclosures, and have provided their informed consent to these.
Signature*
Name*

First NameLast Name
Date*

MonthDayYear
Date
Copy of Participant's NDIS Plan

Please upload the Participant's NDIS Plan. Blanked out dollar amounts is fine.
Participant's NDIS Plan

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Should be Empty:

Excursions - SERVICE AGREEMENT & SCHEDULE OF SUPPORTS

Participant Details:

The NDIS and this Service Agreement

NDIS Participant / NDIS Participant’s Representative Consent

NDIS Participant / NDIS Participant’s Representative Consent  