Gaming Program Expression of Interest

Gaming Program Expression of Interest

Submit your interest in joining our gaming program for NDIS participants at Bright Star Support Services SA Pty Ltd.
Participant Full Name

First NameLast Name
NDIS Number
Date of Birth

DayMonthYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Plan Nominee (if Applicable)

First NameLast Name
Plan nominee email
example@example.com
Plan Nominee contact number
Please enter a valid phone number.Format: (000) 000-0000.
- We ask that you write any diagnoses applicable to attend this program and the supports you may require that will allow you access to participate in the program.
  
  Examples may be:
  
  I require my headphones if the noise volume becomes too loud.
  
  I require fidgets available to support my snesory regulation.
  
  I require a break out space if i become overwhelmed and need some time to reset myself.
- Primary Diagnosis / Support Needs
- Mobility or Communication Considerations
- Preferred Gaming Platforms
  
  Other
- Gaming Interests
- Preferred Support Ratio
- Transport Needs
- Behaviour or Risk Considerations
- Emergency Contact Name
- Emergency Contact Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Funding Management
- Additional Comments
- I consent to receiving communication about the next steps to register with Bright Star Support Services Sa Pty Ltd.
- Signature of Participant or Representative
Should be Empty: