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*

13-18 years
10-15 years
5-10 years

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.

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Mon - July 5th

5-10 years

9.30am-12.30pm - PUBLIC HOLIDAY

Mon - July 4th

10-15 years

9.30am-4.30pm - JackBox Games, Fremantle Prison & Sand Art ($8 extra will be invoiced)

Tues - July 5th

13-18 years

9.30am-4.30pm - DIY Macrame Keychain, VR-Arrival & Board Games (approx $44 extra will be invoiced)

Wed - July 6th

10-15 years

9.30am-4.30pm - JackBox Games, Cat Cafe & Card Games (approx $25 extra will be invoiced)

Thurs - July 7th

13-18 years

9.30am-4.30pm - Submarine Tour, Lunch @ Cicerellos & Stained Glass Art (approx $7.50 extra will be invoiced + please bring money for lunch)

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Fri - July 8th

5-10 years

9.30am-12.30pm - Environmental Day Activities

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Mon - October 4th

5-10 years

9.30am-12.30pm - Maleficent Theme Party - Craft & Puppet Show

Mon - July 11th

10-15 years

9.30am-4.30pm - JackBox Games, Nostalgia Box Museum & Paracord Crafts ($13.20 extra will be invoiced)

Tues - July 12th

13-18 years

9.30am-4.30pm - Painting & WA Museum ($10 extra will be invoiced)

Wed - July 13th

10-15 years

9.30am-4.30pm - Submarine Tour, Picnic @ Esplanade Park & Cultural Diversity ($7.50 extra will be invoiced)

Thurs - July 14th

13-18 years

9.30am-4.30pm - Punch Needling & Cinema ($20 extra will be invoiced)

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Fri - October 8th

13-18 years

9.30am-4.30pm - Push the Button, Movie & Aboriginal Festival ($23 extra will be invoiced)

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Fri - July 15th

5-10 years

9.30am-12.30pm - Winter Experiments

NRF - Non-refundable - Booking required

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

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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*

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Name

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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

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