Sparkle Summer School Holiday Program 2024-2025 Registration Form

Autumn Holiday Program April 2025

Register for our upcoming Summer School Holidays!
April 14th - April 25th 2025
Participant Details
Participant’s Full Name:*

First NameLast Name
{participantsFull:first}'s Date of Birth:*

DayMonthYear
Date
{participantsFull:first}'s Gender:

MaleFemaleOther
{participantsFull:first}'s Address*

Street Address

Street Address Line 2

SuburbState

Postcode

About the Participant
{participantsFull:first}'s NDIS Number*
Please enter Participant’s 9 digit NDIS Number
How is {participantsFull:first}'s NDIS plan managed?*

Plan-ManagedAgency-ManagedSelf-Managed
Please provide Plan Manager’s name:

First NameLast Name
Please provide Plan Manager’s email:
Please provide {participantsFull:first}'s diagnosis and/or medical conditions:*
Please detail what supports {participantsFull:first} will require:
Please provide as much detail as possible
Please detail any of {participantsFull:first}'s behaviours of concern. Please include details of triggers:
Please provide as much detail as possible

Participant's Medical Information
Please list any dietary requirements and/or allergies:
Leave blank if not applicable
Does {participantsFull:first} require regularly prescribed medication throughout the day?*

YesNo
Does the {participantsFull:first} administer their medication independently, or do they require assistance with medication intake?

Administers medication independentlyRequires assistance with administering medication
Please complete this question accurately. Supply any medications in its original packaging with {participantsFull:first}'s name and dosage. If a blister pack is required, please advise Sparkle Management.
Please provide details about medications, including name, dosage, method, and time taken:

Confirmation
Confirmation:

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Full name of the person completing form:*

First NameLast Name
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Please sign:*

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Autumn Holiday Program April 2025