Lets Get Booking! Once we have received booking form we will forward a service agreement for you to sign. Participant Information * First Name Last Name D.O.B Gender Age Address Address 1 Address 2 City State/Province Zip/Postal Code Country Parent/Caregiver Information Name First Name Last Name Relationship to participant Phone (###) ### #### Email Preferred method of contact Phone SMS Email About the Participant Does the applicant have any cultural, spiritual or religious needs? (If yes please describe) Yes No Does the applicant have a personal risk assessment plan? (please provide) yes no Does the applicant have their money looked after? yes no Does the applicant have any dietary requirement or a mealtime management plan? (please provide) yes no Is the participant a smoker? Yes No Is the participant able to have alcohol? yes no Is the participant inclined to wander? yes no How does the participant communicate Does the participant have any phobias? Yes No If yes, please describe Does the participant have hearing difficulties yes no Behaviours of concern (please provide plan) yes no Does participant need help with showering? yes no Does participant need help with personal care/toilet? yes no Is participant aware of stranger danger? yes no Is participant aware of pool safety? yes no Is participant aware of road safety? yes no Is participant aware of heights? yes no Some foods I like are Some foods I dislike are Some things I like are Some things I dislike are Is there anything else we should know/be aware of that would make your time with us more enjoyable? Medical Information Disability * Please provide details of any medication participant is required to take * Problems with swallowing food, fluids or medication * yes no Does the participant suffer from blackouts or dizzy spells? * (If yes please describe) yes no Asthma (please provide management plan) yes no Bed wetting yes no Diabetes (please provide management plan) yes no Seizures/Epilepsy? * Please provide management plan yes no Allergies? * (if yes please describe) Yes No NDIS No Thank you!
