Clone of Wonder Learnerz – Expression of Interest Form

1
Guardian Name* This field is required.
First Name
Last Name
2
Relationship to Young Person* This field is required.
3
Phone Number* This field is required.Main Guardian
Area Code
Phone Number
4
Email* This field is required.Main Guardian
example@example.com
5
Preferred contact method* This field is required.
Phone call
Email
SMS
6
Young person`s Date of Birth* This field is required.
Date
Day
Month
Year
7
Young person`s Gender* This field is required.
8
Does the young person currently attend any day program, or school?* This field is required.
YESNO
9
If Yes, please provide the name of the service/school.
10
If No, please provide the reasons.
11
What language/languages do you speak at home (with the young person)?* This field is required.
12
What activities does your young person enjoy?* This field is required.Select all that apply
Music
Gaming
Sensory activities
Swimming
Movies
Arts & crafts
Community outings
Cafés/restaurants
Sports/recreation
Nature/walks
Cooking
Other
13
What environments does your young person prefer?* This field is required.Select all that apply
Quiet/low sensory
Small groups
Outdoor activities
Indoor activities
Structured routine
Flexible/free-flow activities
Other
14
What would you hope your young person gains from Wonder Mates?* This field is required.Select all that apply
Friendships and social connections
Increased confidence
Community participation
Independence skills
Emotional wellbeing
Routine and engagement
Fun and enjoyment
Other
15
What are your main goals for your young person through Wonder Mates?* This field is required.Select all that apply
Building confidence
Social connections and friendships
Transitioning safely into adulthood
Building independence slowly at their own pace
Community participation
Emotional well-being and regulation
Learning life skills
Reducing isolation
Developing routine and engagement
Feeling safe and accepted
Other
16
preferred days of the week* This field is required.
Monday
Tuesday
Wednesday
Thursday
Friday
17
Preferred duration* This field is required.*excluding Transport
3hrs slot
4hrs slot
5hrs slot
Other
18
Preferred Times* This field is required.
Morning
Afternoon
Evening
Other
19
Would you prefer?* This field is required.in a small group sitting
1:1
1:2
NON NDIS
20
Would you need transport?* This field is required.with additional fees
YESNO
21
What made you interested in Wonder Mates?* This field is required.
22
How did you hear about us?* This field is required.
Facebook
Instagram
Word of mouth
School
Therapist recommendation
Other
23
I consent to Wonder Kidz contacting me regarding Wonder Mates enrolment.* This field is required.
YESNO
24
Would you like to receive updates about Wonder Mates programs, outings, and future activities?* This field is required.via Emails only
YESNO
25
Guardian Signature* This field is required.
26
Date* This field is required.
Date
Day
Month
Year
Should be Empty: