ASDESI Intake form

Name of Child

Date of Birth

NDIS Number (If Applicable) - Please note you do not need an NDIS plan to attend ASDESI Kids Klub

NDIS Plan Start Date

NDIS Plan End Date

Does your NDIS Plan have Social and Community Participation funding?

Yes No

Name of Primary Carer

Relationship to Child

Parent Grandparent Other

Address

Phone Number

What days of the ASDESI Kids Klub would you like your child to attend?

What school does your child currently attend?

Grade/year

So that we can better understand your child's behaviour in a group setting, Has your child been suspended/excluded from school or another vacation care program? If yes, please provide details.

Are there any specific triggers for these behaviours that we should be aware of?

How are these behaviours managed at home and is there anything we should know that will help us better support your child?

Does your child have any support plans? (behavior, epilepsy etc)

Upload any support plans

Has your child received an official diagnosis?

If yes, please attach any relevant documentation e.g doctor's letter

Does your child require 1:1 support from a support worker?

Doctor's Name

Name of Surgery

Doctors Phone Number

Medicare Number

Medicare Reference

Medicare Card Expiry

Does your child have any other health conditions?

If yes please attach any relevant documentation e.g doctor's letter or epilepsy management plan.

Does your child take any medication? Please note that all medication must be provided in a Webster-Pak.

If yes, please give details on the name of the medication, condition it is used to treat, dosage and time of day to be taken.

Upload any relevant documentation for medication here:

Does your child have any allergies or dietary requirements?

Please list all allergies and dietary requirements

If you child suffers from Anaphylaxis, please attach their ASCIA plan here

Name of Primary parent/carer with whom the child lives

Relationship to the child

Primary Phone Number

Secondary Phone Number

Does this person have permission to drop off/pick up the child from the ASDESI Program?

Name of Secondary parent/carer

Relationship to the child

Primary Phone Number

Secondary Phone Number

Does this person have permission to drop off/pick up the child from the ASDESI Program?

Is there anyone else who you authorise to drop off/pick up the child from the ASDESI Program? Please provide their full name and relationship to the child.

Upload Photo ID (Drivers Licence) for other authorised representative/s

Are there any court orders or AVO's in place relating to this child? Please provide details.

I understand that from time to time Interchange Australia may take photos and/or videos of the children participating in activities. These photos and/or videos may be used in future marketing material for the ASDESI and 4K programs. If you require your child's face to be blurred in images please advise us of this.

Declaration: I understand that there are inherent risks of personal injury involved in the ASDESI Holiday Kids Klub, and I agree that my child participates in activities at his/her own risk. In the case of an emergency, I authorise Interchange Australia to arrange for my child to receive emergency medical treatment/s including ambulance transport that may be required. In the case of a cancellation with less than 2 business days notice, you will still be charged for the full price of the activity. Should we have to cancel or postpone an activity due to unforeseen circumstances, a replacement activity will be organised in it’s place. If the program is cancelled for the day, you will not be charged. Please note that all ASDESI fees must be paid PRIOR to the holiday program commencing. Any past outstanding invoices must also be paid before your booking will be confirmed. I have read and understand the information in this application. I declare that the information provided in this registration form is, to the best of my knowledge and belief, accurate and complete. I understand that this application is subject to approval by Interchange Australia.