A2A Groups – Expression of Interest
We’re excited to introduce new social groups for NDIS participants. Complete this expression of interest to tell us which group you’re interested in and what support you may need. This is an expression of interest only. Our team will contact you to discuss availability, costs, funding and confirm your place.
Participant details
Participant name
*
First Name
Last Name
NDIS number
Participant email address
*
example@example.com
Participant phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How is the participant’s NDIS plan managed?
*
NDIA-managed
Plan-managed
Self-managed
Not sure
Not applicable / not an NDIS participant
Plan manager name
Plan manager email
example@example.com
Who should we contact about this interest form?
*
Participant
Someone else
Contact person’s name
First Name
Last Name
Contact person’s email
example@example.com
Contact person’s phone
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to participant
Preferred contact method
*
Phone call
Text message
Email
Group interest
Which group are you interested in?
*
Women's Night – monthly women’s group
Other
If Other, what type of group would you like A2A to offer?
Which date are you interested in?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you require transport?
*
Yes – pick-up and drop-off
Pick-up only
Drop-off only
No
Not sure
Pick-up / drop off suburb
Will the participant bring their own support worker?
*
Yes
No
Not sure
Accessibility, communication, dietary or other support needs
Funding and billing
Which funding option or line item may apply?
Core – Assistance with Social, Economic and Community Participation
Capacity Building – Increased Social and Community Participation
Capacity Building - Improved Daily Living – 15_045_0128_1_3 Community Engagement Assistance
Self-funded
Not sure – please contact me
Other
Other funding or line item
Anything else you would like us to know?
I would like to hear about future A2A groups and activities.
I would like to hear about future A2A groups and activities.
Submit expression of interest
Should be Empty: