Friendship Explorers Expression of Interest
For NDIS participants aged 6-14 years
Participant Details
Participant's Name
*
First Name
Last Name
NDIS Number
*
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Start date of NDIS Plan
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
End date of NDIS Plan
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Nominee Details
Parent/Nominee Name
*
First Name
Last Name
Email
*
example@example.com
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
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NDIS Participant Plan Details
How is your plan managed?
*
Please Select
Plan Managed (Please provide details)
Self Managed
Agency Managed
Plan Manager name (if applicable)
Plan Manager email address
example@example.com
Plan Manager phone
Please enter a valid phone number.
Format: (000) 000-0000.
I give permission for Connextions to contact my Plan Manager in order to determine if funding is available and the relevant categories for the services I have requested, as well as to prepare a service agreement
Yes
No
Support Coordinator Name (if applicable)
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
I give permission for ConneXtions to contact my Support Coordinator to support with the completion of the service agreement, funding details and categories.
Yes
No
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Next
Education
School child attends (if applicable)
Does your child have a diagnosis and if so please, tell us a little about the participant and their needs. What would you like as an outcome of attending the program?
I give permission to be contacted to advance this service request and discuss availability
Yes
No
Please sign
*
Submit
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