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.

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Mon - July 5th

5-10 years

9.30am-12.30pm - PUBLIC HOLIDAY

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Mon - July 4th

10-15 years

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

Tues - September 27th

15-18 years

9.30am-4.30pm - Outdoor Laser Tag Excursion, BBQ Lunch, Melty Beads & JackBox Games ($37 extra will be invoiced)

Wed - September 28th

10-15 years

9.30am-4.30pm - Clay Magnet, Strike Bowling & Nerf War ($20 extra will be invoiced)

Thurs - September 29th

15-18 years

9.30am-4.30pm - Ice Breaker Games, Indoor Volleyball & In-house Movie ($5 extra will be invoiced)

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Fri - September 30th

5-10 years

9.30am-12.30pm - Hip Hop Dancing, Target Practice & Baking Cupcakes

Fri - September 30th

10-18 years

1.30pm-4.30pm - Video Game Competition hosted by Youth Council

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Fri - September 30th

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 - October 3rd

10-15 years

9.30am-4.30pm - Outdoor Laser Tag Excursion, BBQ Lunch, Melty Beads & JackBox Games ($37 extra will be invoiced)

Tues - October 4th

15-18 years

9.30am-4.30pm - Quiz, Resin Craft, Baking Cookies & Ice Arena ($25 extra will be invoiced)

Wed - October 5th

10-15 years

9.30am-4.30pm - Fire Station Museum, Picnic Lunch @ Wellington Square, Perth City Farm, Video Game Competition

Thurs - October 6th

15-18 years

9.30am-4.30pm - South Fremantle Beach, Fish & Chips @ South Beach Cafe & Embroidery Stitching (Bring own pocket money for fish & chips)

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Fri - October 7th

5-10 years

9.30am-12.30pm - Yoga Session, Mindfulness Painting, Build a Racecar Track, Plane Flying Competition

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Fri - July 15th

5-10 years

9.30am-12.30pm - Winter Experiments

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

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Comments

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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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