Clone of Tweenz Summer Holiday

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Follow us to get the latest news about our exciting adventuresjoin our Wonder Family

2

Are you new to the Wonder Family?* This field is required.

YESNO

3

Tween Name* This field is required.

First Name

Last Name

4

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

YESNO

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

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Primary Carer Name* This field is required.

First Name

Last Name

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Primary Carer Email* This field is required.

example@example.com

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Primary Carer Phone Number* This field is required.

Please enter a valid phone number.

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Date of Birth * This field is required.

Date

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Gender* This field is required.

Male

Female

Other

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Is the Tween considered* This field is required.

An Aboriginal

No

Torres Strait Islander

12

Tween Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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School* This field is required.

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Diagnosis* This field is required.

15

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

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

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Self feeding* This field is required.

YESNO

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Self toileting* This field is required.

YESNO

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Is the Tween an NDIS participant?* This field is required.

YESNO

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NDIS Number* This field is required.

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The plan is* This field is required.

Self-managed

Plan Managed

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Billing Email* This field is required.

example@example.com

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Cultural Background* This field is required.

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Dietary Requirements* This field is required.

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Kindly upload the latest NDIS funding statement from your plan manager or a screenshot of your child`s My 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

27

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

1:1 = 70.0 $/hr

1:2 = 40.0 $/hr

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

YESNO

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Behaviours of concerns* This field is required.

Absconding

Self harm

Harming others

others:

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

YESNO

31

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

32

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

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Allergy cause* This field is required.

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

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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

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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

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

YESNO

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Medication Name* This field is required.AS Labelled

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Dosage given:* This field is required.

As prescribed by the doctor

As instructed on the packaging

As needed.

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

YESNO

41

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

YESNO

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

YESNO

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Transportaion?* This field is required.

Pick Up from home only

Drop Off home only

Both

Parents will transport

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Billing Out of ?* This field is required.

Core Funding : Social activities

Capacity building: Therapy

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

YESNO

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

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

YESNO

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

First Name

Last Name

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Emergency Contact Phone Number* This field is required.

Please enter a valid phone number.

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Form filled by:* This field is required.

First Name

Last Name

51

Date* This field is required.

Date