AkinCare Provider Registration Form

Provider Registration Form
At AkinCare, we believe exceptional care begins with exceptional providers. By joining us, you're connecting with a network of like-minded small businesses dedicated to collaborative success and superior client outcomes. Please complete this form to begin your registration; our team will be in touch shortly to welcome you aboard!
BUSINESS IDENTITY INFORMATION
TODAY'S DATE*

DayMonthYear
Date
Legal Entity Name:*
Trading Name: (if different from above)
CompanySole TraderPartnershipNot-For-Profit
ABN Number:*
Website:
Address:*
Primary Contact:*
Position:*
Contact Tel#:*
Please enter your best cntact telephone number without spacesFormat: (000) 000-0000.
Email :*
example@example.com
REGISTRATION STATUS
YesNo
NDIS Registration Number:
YesNo
YesNo
COMPLIANCE & SUITABILITY
Key Personnel Names: (Directors, CEOs Managers)*
Have any Key Personnel ever:
YesNo
YesNo
YesNo
YesNo
WORKFORCE & SCREENING REQUIREMENTS
At AkinCare, we prioritize the safety and dignity of our clients. To meet our legal obligations under the Aged Care Act 1997, the Aged Care Act 2024 and relevant other legal frameworks, we require all providers—including {legalentity}—to operate in full compliance with these regulatory frameworks.

By proceeding, you declare that all employees, Team Members and volunteers under {legalentity} maintain current and valid clearances for the following:

The Providers workforce have the current checks held on file and they will be made available to AkinCare should they request evidence in the future:*

Rows	Yes	No	N/A
Valid NDIS Worker Screening Check?
Current National Police Check?
Working With Children Check?
NDIS Worker Orientation Module?

Provider Registration Form