Hale Mates Registration Form

Hale Mates Registration Form

To become a Hale Mate, we first need to gather some important information. Please fill in and submit this form, which will be automatically sent to Kymberley.

If you need further information, please contact Kymberley at kymberley@neuromuscularwa.org.au or call our office on 08 9380 3400.

About Your Child
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Does your child have a neuromuscular condition?*

YesNo, they are a sibling of someone with an NMC
Type of neuromuscular condition*
Other health conditions
Address*

Street Address

Street Address Line 2

SuburbState / Province

Postal Code
Parent/Guardian Details
Name*

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

First NameLast Name
Emergency Contact Phone Number*
Please list all the names & contact numbers of any additional people who will be bringing your child.

Equipment Details & Mobility
Please ensure you provide any equipment you will require during the program. Neuromuscular WA does not provide any personal care equipment for the Hale Mates program.
Walking*
Equipment used and any further details:
Transferring*
Equipment used and any further details:
Toileting*
Equipment used and any further details:
Please note, support workers will not be provided at the Hale Mates Program. If assistance is required in toileting it is the responsibility of the parent/guardian/support worker of the participant. If you have any concerns, please contact Kymberley to discuss further.
As the child you are registering does not have a neuromuscular condition, please press next to continue the registration process.

Hospital Emergency Plan
Who to contact in the event of an emergency?*

First NameLast Name
Best Contact Number*
Although we hope it will never be required, the complexities of certain types of neuromuscular conditions create the need for a Hospital Emergency Plan to be in place for each participant. The hospital emergency plan will provide relevant infrmation 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 provide details of the participant's GP and any specialists regularly involved in their care:
GP Name & Phone Number:
Specialist Name & Phone Number
Medicare and Private Health Insurance details:
Medicare Number:
Private Health Insurance Provider & Policy Number:
Please advise of any specific directives that you would like the Neuromuscular WA staff to communicate to paramedics in the event of emergency?
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.

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 attending 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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About Your Child