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 her at 0432 355 884.
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
Secondary Contact Name (different to above)*

First NameLast Name
Secondary Contact Phone Number*
Please list all the names & contact numbers of any additional people who will be bringing your child.
Participant Health & Medical Information
Does the participant have any of the following? (Please select as many as apply)

Anaphylaxis*Asthma*Autism Spectrum Disorder*Circulatory disordersConstipationDepressionDiabetes*DiarrhoeaEnteral (PEG) feeding*Epilepsy*Hay feverHeadachesIncontinenceSevere or minor allergies*Skin conditionsSleep ApnoeaSubstance abuseVision impairment
We require a care plan to be provided if any of the following conditions are present; diabetes, enteral (PEG) feeding, 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 an allergy or autism spectrum disorder 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.
Cancelof
Are there any behaviours to consider for your child that may impact their enjoyment during Hale Mates?
Does your child have any food allergies?*

YesNo
Please list all food allergies below*
Please let us know of any special requirements or things to note that you would like staff to be aware of?
Equipment Details & Mobility
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.

Please ensure you bring 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:
Emergency Situation
Who to contact in the event of an emergency?*

First NameLast Name
Best Contact Number*
GP Name & Phone Number:
Specialist Name & Phone Number
Medicare Number:
Private Health Insurance Provider & Policy Number:
In an emergency the first contact person on this form will be called first, followed by the second contact person.

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.
Please advise of any specific directives that you would like the Neuromuscular WA staff to communicate to paramedics in the event of emergency?
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.
Should be Empty:

About Your Child

Parent/Guardian Details

Participant Health & Medical Information

Equipment Details & Mobility

Emergency Situation