Jesus Club EOI (Ballarat)

Jesus Club

Want to come along to Jesus Club? Let us know a bit more about you!
Name*

First NameLast Name
Date of Birth (so we can celebrate your birthday!)

MonthDayYear
Date
Phone Number*
Please enter a phone number.Format: (04) 0000-0000.
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*
Please enter a valid phone number.Format: (00) 0000-0000.
Dietary Requirements/Allergies
If you have an allergic reaction, what do we need to do to keep you safe?
How will you be getting to and from Jesus Club?
Who can we call if you need to get home?

NamePhone Number
What do you like doing?
Is there anything you strongly dislike/fear?
YesNo
What are your behaviours of concern and how do we best manage them?
Please attach any supporting documents that you think we’d find helpful

Cancelof
YesNo
What are your physical concerns and how do we best manage them?
Please attach any supporting documents that you think we’d find helpful

Cancelof
Anything else we should know?
YesNo
Please Note: If you require support with feeding, toileting, or any other specialised supports, please arrange to bring a support worker with you to Jesus Club as we are not able to provide these types of support.
Should be Empty: