Telethon Holiday Makers Expressions of Interest - Rockingham

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.

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.

Tues - September 27th

10-18 years

9.30am-4.30pm - Outdoor Laser Tag Excursion, Picnic Lunch @ Bibra Lake & Craft/Painting ($37 extra will be invoiced)

Thurs - September 29th

10-18 years

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

Tues - October 4th

10-18 years

9.30am-4.30pm - Rope Coaster Craft, Origami Craft, In-house Movie & Quiz ($10 extra will be invoiced)

Thurs - October 6th

10-18 years

9.30am-4.30pm - Ice Breaker Games, Penguin Island & Video Game Competition ($31.50 extra will be invoiced)

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.

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Email

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Telethon Holiday Makers Expressions of Interest – Rockingham

Rockingham Holiday Expression of Interest Form

Section 1 - Participant's Details

Section 2 - Session Details

Section 3 - Funding

Section 4 - Contact Details

ALERT