Telethon Holiday Makers Expressions of Interest - Cockburn

Section 1 – Participant's Details

Name*

Date of Birth*

Suburb*

Which suburb do you live in?

Does the participant have any of the below cards? If so please bring these for each day attending*

Please tick all that apply.

Companion Card
Concession Card
Student Card
SmartRider Card
None of the above

If participant does not have a SmartRider, exact change for public transport will be required.

Has the participant attended a social support program at Spectrum Space?*

Either in the past or current.

Yes
No

Which social program do/have they attend/ed?

In what year did the participant last attend the above program?

Section 2 – Session Details

This section will appear when you select the Age of Participant above.

Mon – January 13th

10-18 years

9am-4pm – Mosaic Coasters, Quiz, Board Games, Park Fun/Picnic, Bottle Rocket & Ice Arena ($13 extra will be invoiced)

Mon – January 20th

10-18 years

9am-4pm – BBQ and Cultural Activity, Beading, Nature Scavenger Hunt, Outdoor Games & Birds of Prey ($30.85 extra will be invoiced)

The Program for 29th September is hosted by Spectrum Space’s Youth Advisory Council and will take place in Willagee (not our office in Fremantle). Further details will be provided to you on enrolment.

Section 3 – Funding

NOTE: You can use your NDIS funding to access our services.

Funding*

Self Funded (all program sessions are paid by you with no reimbursement from any external body)
Funded (Program sessions are partially or fully funded by an external body such as NDIS, CRCC or similar)

NDIS Funding*

Do you have NDIS funding?

Yes
No

Hidden

How is your NDIS Plan managed?*

Self Managed
NDIS Managed
Agent Managed

How is your NDIS Plan managed?*

Please note that if your plan is managed by the NDIA (also called agency managed) you cannot use that NDIS funding to access our services. There are ways we can help you to access our services if your plan is NDIA managed, so please contact enrolments@spectrumspace.org.au or call our office on 08 9431 2111 for a chat about your options.

Self Managed
Plan Managed

Name of Funding Organisation

Section 4 – Contact Details

Name*

Contact Number*

Email*

How did you hear about us?*

If Other, please specify*

ALERT

It appears you have not selected which days you would like to attend, please go back to Section 2 before you submit the form.

Hidden

Waitlist Alert!

You have selected at least one day which is at capacity, you will be added to a waitlist for these days.

Safety Disclaimer and Liability Waiver*

When enrolling your child in Telethon Holiday Makers activity, you must be aware of all possible risks associated with participation in that chosen activity, particularly those involving physical activity. It is entirely your responsibility to decide whether or not the activity offered as part of the Program is appropriate for your child/children’s capabilities, aptitude, fitness and health. Despite all attempts to keep your child/ren safe while in our care, Spectrum Space is not liable for any accident or injury that may occur in the course of participation scheduled activities. Your enrolment/registration serves as an acknowledgement of these risks. All participants will be required to adhere to the strict terms and conditions and safety conditions as individually prescribed in relation to the activity they are attending. We would encourage you to explore these conditions in depth through any external provider websites in advance of attending and discuss the matter of safety with your child. The limitations and exclusions in this paragraph only apply to the extent permitted by applicable law.

Agree

Phone

This field is for validation purposes and should be left unchanged.

Telethon Holiday Makers Expressions of Interest – Cockburn

Cockburn Holiday Expression of Interest Form