Event Registration | Independent Living Care

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ABOUT
NDIS
SERVICES
- Book A Catch Up
FORMS
CONTACT
BLOG
More

Use tab to navigate through the menu items.

SHOP

ABOUT
NDIS
SERVICES
- Book A Catch Up
FORMS
CONTACT
BLOG
More

Use tab to navigate through the menu items.

Participants Registration of Interest form

Participant Name

Participant D.O.B.

Parent/Guardian Name

Email Address

Home Address

Phone Number

Accommodation Services (if applicable)

Address

Daytime Contact Number

Participant Interest

Days preferred for future reference

Mon

Tues

Wed

Thur

Fri

Would you look at coming to our monthly events?

Yes

No

Does the participant require transport assistance?

Yes

No

Type of Disability and Level of Support Needsed (medium, high, etc)

If Known, How Will You Pay for the Service?

DCSI Funding

NDIS Funding

Self Funding

Do you have a current NDIS Plan?

Yes

No

Plan Start Date

Plan End Date

Invoices to be emailed to

Specific Support Requirements

Toileting

Mobility

Medications

Communication Verbal/Written

Behavioural

Dietary Requirements

Allergies

Any health conditions we need to be aware of?

Additional Info

What are his/her current goals?

What are his/her current goals? What other goals he/she would like to achieve?

Emergency Contact 1

Name

Relationship To Participant

Email Address

Home Address

Phone Number

Emergency Contact 2

Name

Relationship To Participant

Email Address

Home Address

Phone Number

Additional Notes

Thanks for submitting!

OFFICE USE ONLY: Checklist to be completed by ILC Staff member – Please initial and date once completed.

Disability coordinator has been given contact details:

Date Completed

By Who

Your Signature

Invoices to be sent to:

Date Completed

By Who

Your Signature

Correspondence to be sent to:

Date Completed

By Who

Your Signature

Added to database (inc.mail out list)

Date Completed

By Who

Your Signature

Contract received and signed (make a file):

Date Completed

By Who

Your Signature

Added to pick up sheet:

Date Completed

By Who

Your Signature

Medical information returned:

Date Completed

By Who

Your Signature

Transport arrangements, if any:

Date Completed

By Who

Your Signature

Confirmation Letter sent out:

Date Completed

By Who

Your Signature

Invoice information for that quarter given to appropriate personnel:

Date Completed

By Who

Your Signature

Senior staff been informed of new participant:

Date Completed

By Who

Your Signature

Added to invoice/funding spread sheet:

Date Completed

By Who

Your Signature

Communication book made:

Date Completed

By Who

Your Signature

Email to: cate@independentlivingcare.com.au

Date Completed

By Who

Your Signature

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