NDIS/ Child Safety KKT Camp Enrolment Form

Kool Kids Camp Enrolment Form

ABN: 55 637 079 620
State (please tick)*

QueenslandSouth AustraliaNew South WalesWestern AustraliaVictoriaNorthern TerritoryAustralian Capital TerritoryTasmania
Residential Suburb*
Which venue are you enrolling for?*

Bestbrook Mountain ResortCYC Burleigh HeadsOther
Personal Details
Full Name*

First NameLast Name
Gender*
Birthdate (DD/MM/YYYY)*

DayMonthYear
Date
Email (of guardian)*
example@example.com
Medicare Number*
Medicare Number on Card*
Medicare Expiry Date*

DayMonthYear
Date
Private Health Insurance (if applicable)
Private Health Insurance Provider
Private Health Insurance Number or Details
Additional Information

Are there any family, behavioural or medical conditions which we should be aware of? If the condition is not mentioned below, please state in the additional notes section below.

	Yes	No
ADD/ADHD
Autism Spectrum Disorder
Hearing/Sight Impairment
Formal Counselling, Depression or other issues that may affect the participant on the event?
Is there any restriction on activities?
Bed Wetting
Sleep Walking
Travel Sickness

Swimming Ability*

PoorFairly WellStrongOther
Additional Notes/Other:
Dietary Requirements
Do you have any dietary requirements?

VeganVegetarianGluten FreeDairy FreeAllergiesOther
Additional Notes
Camper Details
Who were you referred by? (e.g. school/organisation)
How did you hear about our camp?*

Previous camp at the same venueChurchSchoolChaplainFacebookGoogle SearchWord of mouth
Have you been to this venue before?*

YesNo
In case of an emergency or a serious injury, do you give us permission to call emergency services (e.g. ambulance/police/fire department) as the first point of contact?

YesNoOther
Emergency Contact 1
Full Name*

First NameLast Name
Relationship to Participant*
Phone Number *
Emergency Contact 2
Full Name*

First NameLast Name
Relationship to Participant*
Phone Number*
Child Protection and Safety Information

Empowered Therapy and Training in conjunction with Kool Kids Tutoring is committed to the safety and wellbeing of all children and young people involved in our events. To ensure that children and young people are kept safe from harm, our staff and volunteers are required to possess a current working with children check (e.g. Blue Card); agree to adhere to a code of conduct when working with children and undergo training in child safety. We take child protection and safety matters seriously and consequently has policies and procedures in place to ensure that your child has the best possible experience with us.

Permissions*

	Yes	No
Do you give Empowered Therapy and Training in conjunction with Kool Kids Tutoring permission to share video footage or photographs of your child taken during the camp in both print and digital formats, including our websites?
Do you consent to a camp leader continuing contact with you after the camp to keep you updated about future events?
Do you give Empowered Therapy and Training in conjunction with Kool Kids Tutoring permission to transport your child to and from the venue?

All details contained within this referral form are considered to be private and confidential.

Responsibilities of the Provider

The provider agrees to:

1. Support the participant to achieve their goals, meet their needs and requirements and sensitively respond to and support their rights to practice their cultural diversity values and beliefs.

2. Communicate openly & honestly in a manner and mode in which the participant is most likely to understand, in a timely manner and where needed, we will use Auslan and or language interpreters
Payment
You may pay online (see below) or complete a bank transfer using the following details. If you complete a bank transfer, please forward your receipt to: finance@empoweredtherapyandtraining.com.

Name: Kool Kids Tutoring PTY LTD

BSB: 484-799

Acc Number: 050103780

Please add your name and 'KKT Camp' in the reference: e.g. Katie KKT Camp.

If you are an NDIS or CHILD SAFETY participant, please provide your billing address accurately (support coordinator, plan manager, self-administrator, etc.).

For example.: name, email, phone number, organisation

Email referrals@empoweredtherapyandtraining.com if you have questions.

Thank you!
Are you an NDIS or Child Safety participant?*

NDISPrivateChild Safety
NDIS Number
We believe every family should have access to camp. That's why we offer several flexible payment options to suit your needs.

Payment Options:
1. NDIS Funding: We are a registered provider and can help you utilise your plan.
2. Split Payments (Fortnightly): Spread the cost over two fortnights with Ezypay. Total: $1,399 (ex. GST) | Fortnightly: $699.50
3. Buy Now, Pay Later: Secure your spot instantly using eWay.
4. Pay in Full: Make a one-time payment via bank transfer or credit card. Total: $1,399 (ex. GST)
Bank Transfer Details (for Pay in Full):
Account Name: Kool Kids Camps
BSB: 484-799
Account Number: 050103780
Please include the child's full name as the payment reference.

Don't let payment questions hold you back! We're happy to help find a solution that works for your family.
How will you be paying?*

NDISEzyPay - Split PaymentsEWay - Buy Now, Pay LaterPay in Full
Please send invoice to:

This is the email address we should send invoices to
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Organisation
Plan Managers, Support Coordinators, Child Safety, NDIS, etc
Should be Empty:

Kool Kids Camp Enrolment Form

Personal Details

Private Health Insurance (if applicable)

Additional Information

Dietary Requirements

Camper Details

Emergency Contact 1

Emergency Contact 2

Payment

Please send invoice to: