Telethon Holiday Makers Expressions of Interest - Fremantle

Section 1 – Participant's Details

Name*

Date of Birth*

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.

Age of Participant*

15-18 years
10-15 years
5-10 years

Unfortunately we have reached full capacity for both the 5-10 days. Please try again next school holidays.

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

Either in the past or current.

Yes
No

Which social group do/have they attend/ed?

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

Section 2 – Session Details

This section will appear when you select the Age of Participant above. Any days that are already full will be removed from view.

Mon – July 3rd

10-15 years

9.30am-4.30pm – Sushi Making, Werewolf Card Game & Rock Climbing ($25 extra will be invoiced)

Tues – July 4th

10-15 years

9.30am-4.30pm – Card Games & His Majesty’s Theatre ($20 extra will be invoiced)

Wed – July 5th

10-15 years

9.30am-4.30pm – Marble Run Challenge & WA Maritime Museum ($10 extra will be invoiced)

Thurs – July 6th

15-18 years

9.30am-4.30pm – Pillow Case Making & Virtual Reality @ Glowing Rooms ($48 extra will be invoiced)

Fri – July 7th

5-10 years

9.30am-12.30pm – NAIDOC Key Ring, Super Spy Lazer Maze & Party Games

Mon – July 10th

10-15 years

9.30am-4.30pm – Pancake Making, Real-Life Among Us & Nostalgia Box ($14 extra will be invoiced)

Tues – July 11th

10-15 years

9.30am-4.30pm – Pillow Case Making & Indoor Volleyball ($5 extra will be invoiced)

Wed – July 12th

10-15 years

9.30am-4.30pm – Cicerello’s & WA Shipwreck Museum ($17 extra will be invoiced)

Thurs – July 13th

15-18 years

9.30am-4.30pm – Video Game Arcade @ Escape Portal ($13 extra will be invoiced)

Fri – July 14th

5-10 years

9.30am-12.30pm – Yoga, Science Experiment & Party Games

Hidden

Mon – January 23rd

10-15 years

9.30am-4.30pm – Swimming & Driftwood Wall Art ($5.50 extra will be invoiced)

Hidden

Tues – January 24th

15-18 years

9.30am-4.30pm – Crafts & Beyond Skates ($15 extra will be invoiced)

Hidden

Wed – January 25th

10-15 years

9.30am-4.30pm – Art Journaling & Beyond Skates ($15 extra will be invoiced)

Hidden

Thurs – January 26th

15-18 years

9.30am-4.30pm – Crafts Karaoke Movie

Hidden

Fri – January 27th

5-10 years

9.30am-12.30pm – Murder in the Dark, Build a Bridge, Sock War & Flying Carpet

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?*

You can utilise your Social and Community Participation NDIS funding for service if you’re Self or Plan Managed, but not if you are NDIA Managed. If you would like to discuss your options please contact enrolments@spectrumspace.org.au or call our office on 08 9431 2111.

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.

Name

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

Telethon Holiday Makers Expressions of Interest – Fremantle

Fremantle Holiday Expression of Interest Form

Section 1 – Participant's Details

Section 2 – Session Details

Section 3 – Funding

Section 4 – Contact Details

ALERT