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💙Wonder Learnerz 💙

💙Wonder Learnerz 💙

This evidence-based, play-based program supports children in developing emotional regulation, communication, cooperation, and school readiness skills in a safe, sensory-friendly environment. Please complete the form below, and our team will contact you regarding enrolment and suitability.

53Questions

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1
Have you filled out the care plan and the service agreement?* This field is required.
YESNO
2
Little learner Name* This field is required.
First Name
Last Name
3
Any Changes from the last booking?* This field is required.ex: home address, medications, allergies, behaviours...
YESNO
4
Kindly let us know the changes from the last booking* This field is required.ex: home address, medications, allergies, behaviours...
Huge
Large
Normal
Small
Ok
Ok
5
Primary Carer Name* This field is required.
First Name
Last Name
6
Primary Carer Email* This field is required.
example@example.com
7
Primary Carer Phone Number* This field is required.
Please enter a valid phone number.
8
Date of Birth* This field is required.the participant
Date
Year
Month
Day
9
Gender* This field is required.
Male
Female
Other
10
Is the young person considered* This field is required.
An Aboriginal
No
Torres Strait Islander
11
Does the little learner currently attend any day program or school?* This field is required.
YESNO
12
If No, please provide the reasons.
13
If yes, please provide the name of the school/day program.
14
Diagnosis* This field is required.
15
Sensory Preferences (likes, enjoys and calm them down)* This field is required.
16
Sensory Triggers (avoids, dislikes and triggers them)* This field is required.
17
Self feeding* This field is required.
YESNO
18
Self toileting* This field is required.
YESNO
19
Is the little learner an NDIS participant?* This field is required.
YESNO
20
NDIS Number* This field is required.
21
The plan is* This field is required.
Self-managed
Plan Managed
NDIA managed
Out Of Pocket
22
Billing Email* This field is required.
example@example.com
23
What languages do you speak (with the little learner) at home?* This field is required.
24
Cultural Background* This field is required.
25
Preferred days of the week* This field is required.
Monday
Tuesday
Wednesday
Thursday
Friday
26
What set of skills would you hope your young person gains from Wonder learnerz?* This field is required.Select all that apply
Emotional Regulation
Communication Skills
Following Instructions
Social Interaction
Turn Taking & Sharing
Tolerance & Flexibility
Transitioning Between Activities
Attention & Focus
Independence Skills
Behavioral Support
Friendship Building
Other
27
Preferred duration* This field is required.
3hrs
4hrs
5 hrs
we need to discuss it
28
Dietary Requirements* This field is required.
29
Kindly upload the latest NDIS funding statement from your plan manager or a screenshot of the young person`s My Support Budget via the NDIS portal /App.* This field is required.to make sure they have enough funding
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Max. file size: 10.6MB
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30
The Care ratio* This field is required.No Activity fees will be included
1:1 = 70.0 $/hr
1:2 = 40.0 $/hr
BYO Support= 30$/hr
Private: to be discussed
31
Any Behaviours of concerns?* This field is required.IF you choose (YES) , your child is required to be 1:1
YESNO
32
Behaviours of concerns* This field is required.
Absconding
Self harm
Harming others
others:
33
Any Positive Behaviour Support plan ?* This field is required.
YESNO
34
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
35
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
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Select files to upload
Max. file size: 10.6MB
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36
Allergy cause* This field is required.
37
Allergy signs and symptoms* This field is required.ex: rashes, swelling, sweating..
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Large
Normal
Small
Ok
Ok
38
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
39
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
Browse Files
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40
Any medications?* This field is required.*If any needs to be given medication during the session or in case of emergency
YESNO
41
Medication Name* This field is required.AS Labelled
42
Dosage given:* This field is required.
As prescribed by the doctor
As instructed on the packaging
As needed.
43
By selecting YES, I am giving my consent for the staff at Wonder Kidz to administer medication to the little learner as outlined above.* This field is required.
YESNO
44
Transportation?* This field is required.I acknowledge and agree that transportation provided by Wonder Kidz may incur a charge of $1.00 per kilometre with the delivery of my child support
YESNO
45
By selecting YES, I am giving my consent for the staff at Wonder Kidz to transport the little learner in their vehicle.* This field is required.
YESNO
46
Transportaion?* This field is required.I acknowledge and agree that transportation provided by Wonder Kidz may incur a charge of $1.00 per kilometre with the delivery of my child support
Pick Up from home only
Drop Off home only
Both
Parents will transport
47
Billing Out of ?* This field is required.
Core Funding : Social activities
Capacity building: Therapy
Private: to be discussed
48
Responsibility for Fees Not Covered by the NDIS* This field is required.
49
I acknowledge that a CARE plan must be completed prior to this booking* This field is required.
YESNO
50
Emergency Contact Name* This field is required.other than the parent /Guardian
First Name
Last Name
51
Emergency Contact Phone Number* This field is required.
Please enter a valid phone number.
52
Form filled by:* This field is required.
First Name
Last Name
53
Date* This field is required.
Date
Year
Month
Day
Should be Empty:

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