Create & Connect Club Registration/Referral
Register a child or refer a family for the weekly inclusive program (ages 5–15) run by Supportive Pathways Network.
Referrer Details
Referrer Full Name
*
First Name
Last Name
Relationship to Child
*
Referrer Email Address
*
example@example.com
Referrer Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Child Participant Details
Child's Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
Does the child have an NDIS plan?
*
Yes
No
Unsure
Parent/Carer Details
Parent/Carer Full Name
*
First Name
Last Name
Relationship to Child
*
Parent/Carer Email Address
*
example@example.com
Parent/Carer Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Support Needs
Does the child require 1:1 support to participate?
*
Yes
No
Unsure/Discuss
Does the child have any allergies?
*
Yes
No
Allergy Details (if any)
Medical or Behavioral Considerations
Sibling Attendance
Will a sibling attend?
*
Yes
No
Sibling Name(s) and Age(s)
Consent & Agreement
Additional Comments or Information
Submit Registration
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