SHP Registration Form

FUN DAY REGISTRATION FORM

Held on Wednesday 22nd January 2025, at Woodman Point Recreation Camp.

Please fill in this form and submit it by Sunday 5th of January to be a part of the day.

If you have any questions, please reach out to Kymberley on kym@neuromuscularwa.org.au or call 0432 355 884.

Please note that our office will be closed from 18th December to 6th January so if you have any questions about Fun Day during this time, please email kym@neuromuscularwa.org.au and I will respond on my return to the office.
Participant Details
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

SuburbState / Province

Postal Code
Does your child have a neuromuscular condition?*

YesNo, they are a sibling of someone with an NMC
Type of neuromuscular condition*
Other health conditions
Behaviours of concern
What day/s will you be attending School Holiday Program?*

Tuesday 4th July onlyTuesday 11th July onlyBoth days
Please list some of the participant's interests
Parent/Guardian Details
Name*

First NameLast Name
Phone Number*
Email Address*
example@example.com
Emergency Contact Name (different to parent details above)*

First NameLast Name
Emergency Contact Phone Number*
Secondary Emergency Contact Name*

First NameLast Name
Secondary Emergency Contact Phone Number*
Care & Support Information
Will you be bringing your own support worker to Fun Day?*

YesNo
Do you have a preference of gender of support workers assisting you on the day?

No preferenceMaleFemale
Please provide further information about the support worker you will be bringing to the program. *
Please provide an image or scan of your support worker's Working With Children Check.

If you do not currently have access to this information, please collect it and email a scan or image to kymberley@neuromuscularwa.org.au
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Participant Health & Medical Information
Does the participant have any of the following? (Please select as many as apply)

Challenging behaviours* (e.g. running, difficulty following instructions, etc.)Vision impairmentEnteral (PEG) feedingDiabetes*Anaphylaxis*IncontinenceAsthma*ConstipationSleep ApnoeaCirculatory disordersEpilepsy*DiarrhoeaHeadachesDepressionSkin conditionsSevere or minor allergies*ASDOther
*We require a care plan to be provided if any of the following conditions are present; diabetes, anaphylaxis, asthma, or epilepsy. Please note, that further information or a care plan may be requested by coordinator about other health and medical information selected.
If your child has challenging behaviours, please provide further information below. *
Please upload your care plan/s below for all relevant health conditions your child has.*

We require a care plan to be provided if any of the following conditions are present: diabetes, anaphylaxis, asthma or epilepsy.
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Please upload your care plan/s below if you have one for your allergy.

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Is the participant taking any prescribed medications that will need to be administered during the program? Please note, we only need to know of medications taken during the day while your child is in our care.*

YesNo
Please provide details on medication, dosage and time it will need to be administered.*
I give permission for Neuromuscular WA's First Aid Officer to administer the following medication as required:

ParacetamolIbuprofen
Please let us know of any special requirements or things to note that you would like care staff to be aware of?
Mobility

Please indicate the participant's current level of mobility by selecting the relevant options and provide accurate information relating to the participant's equipment needs.
Walking*
Equipment used and any further details:
Transferring*
Equipment used and any further details:
Toileting*
Equipment used and any further details:
Equipment Details

What Neuromuscular WA provides:
- COMMODES: these will be supplied by us
- HOISTS: these will be supplied by us, we use a t-bar attachment hoist that takes loop slings
What the participant needs to bring:
- SLINGS: please provide your own sling
- PERSONAL CARE ITEMS: please provide your own items not listed above
Nutrition
Diet*
Dietary Requirements*
Please upload your enteral (PEG) feeding mealtime management care plan. *

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Portion Size*
Does your child have any food allergies?*

YesNo
Please list all food allergies below*
Hospital Emergency Plan
Although we hope it will never be required, plan will provide relevant information to the coordinator, paramedics and support staff so it is known exactly how to coordinate the care of your child, should an emergency occur.
Please upload your hospital emergency plan below if you have one.

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Please advise of any specific directives that you would like the Neuromuscular WA staff to communicate to paramedics in the event of emergency?
Where will the participant's parents/guardians be located during the program?*
PLEASE NOTE: in the event of an Neuromuscular WA-determined emergency, an ambulance will be called regardless of a family's health insurance or ambulance cover, or our ability to reach an emergency contact.
GP Name:*
GP Address & Phone Number:*
Specialist Name*
Specialist Address & Phone Number:*
Medicare Number:
Private Health Insurance Provider & Policy Number:
DECLARATION 1*

By ticking this box and submitting this form, I declare that the answers I have given in this application and the documents I will provide are true and correct to the best of my knowledge and belief. I declare that I have read and understood all information provided and requested in this application.
DECLARATION 2*

By ticking this box and submitting this form, I acknowledge that my child may be photographed at this event, and photographs taken may be used for promotional materials on Neuromuscular WA's website, social media platforms and/or resources developed and may be shared with sponsors who have provided funding towards the program for use on their marketing collateral. I acknowledge that if I do not want my child to be photographed, I am required to contact the program coordinator prior to the event RSVP date to inform them.
As this document collects personal information, please read our Privacy Policy to understand how we will use and store this information.
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FUN DAY REGISTRATION FORM

Held on Wednesday 22nd January 2025, at Woodman Point Recreation Camp.

Participant Details

Parent/Guardian Details

Care & Support Information

Participant Health & Medical Information

Mobility

Nutrition

Hospital Emergency Plan