ENROLMENT FORM

Participant Details

First Name

Last Name

Gender

Date of Birth

Home Address

Phone number

Participant Email:

Who does the participant reside with?

Language spoken at home / cultural background

Interpreter Required

YesNo

NDIS Information

NDIS Number

Plan Dates - Start & End

Support Coordinator Name and Email

Plan & Self Managed funds. Please note we not yet a registered provider so can't support NDIA managed people.

Self or Plan Managed

Self ManagedPlan Managed

Plan Manager Organisation or Self managed persons name

NDIS Line item to invoice

Invoice Email Address

Representative / Nominee Details

Name of Representative / Nominee

lives with particpant

YesNo

Relationship to Participant

ParentGardianCaregiver

Address

Gender

MaleFemale

Phone Number

Email Address

PARENT / CARER / EMERGENCY CONTACT

Is the emergency contact the same as the nominee details above

Yes - if yes you do not need to complete this section No

First Name

Last Name

Mobile

Relationship to applicant

Lives with Participant

YesNo

About the Participant

Types of Disability

Living Situation

Is the participant Visually impaired

Dietary Requirements

Allergies

Does the participant have a current BSP?

YesNo

Medical Conditions / Diagnosis

Please upload or arrange for BSP to be sent

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Swimming Competency

Strong swimmerNeeds supervisionCannot swim

Support Information

What Supports is your child or participant looking to engage in at Movement Five

Support Staff Gender

Male FemaleDoesn't Mind

1:1 support - What days/ time do you want support?

Participants Interests - Used to match with support staff

Any behaviours that we should be aware of?

YesNo

Details

Please upload a photo of the client to be added to their Caremaster profile for staff identification purposes. If you are filling the form on behalf of someone else please just upload a blank photo if you don't have one. *

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Add a photo of the participants Companion Card if they have one to be added to their profile

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Health Care Information

Medicare Number

Have you been diagnosed as at risk of Anaphylaxis or an Allergic reaction?

YesNo

If yes, please specify details

Please provide details of your medical practitioner

Please upload ASCIA Plan

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Does the participant have any other specific healthcare needs, including any other medical conditions?

YesNo

Details

Will you require medication to be administered whilst attending the Movement Five programs?

YesNo

Details

Goals

Short-term goals

M5 support Goals

Media and Consent

Movement Five Services Pty Ltd may store and share your image (applicants image), sound and video recording digitally on social media

YesNo

Movement Five Services Pty Ltd may use photographs and video recordings in their professional educational material for training purposes, internal and external advertising and marketing, including print media, web content, social media and electronic media (including the internet)

YesNo

Intake form completed by

Relationship to Participant

Signiture - by signing you agree with the information in this client intake form

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