Have you signed up for a Day Trip, Group or Annual Event in the past six months?

Yes

No

Unsure

Services

I am signing up for (select all that apply):

Day Trips

Groups

Annual Events

Which day trips, groups and/or annual events are you signing up for?

Details of person completing this form

I am:

The participant signing up for this service

A person who is signing up on behalf of the participant for this service (e.g. carer, support coordinator)

CONFIRMATION: I am authorised to agree to service on behalf of the participant signing up for this service *

Yes, I am the participant / I am authorised to agree to services on behalf of the participant

I am not authorised to agree to services on behalf of the participant (we will provide this form to the participant and confirm services)

Participant details

These questions are asked to best understand you and the service required. If they are not required to provide service we will list questions as optional - please skip them if you are not comfortable answering them.

First name

Last name

Preferred name

Gender

Date of birth

Preferred contact method

Phone

Email

Address

Primary contact details

Who is the primary contact? (this is the person we contact directly, usually the participant being referred)

Participant

Next of kin

Support Coordinator

Other

Full name:

Phone number

Email address:

Does the participant have an authorised decision maker?

Yes

No

Full name:

Phone number:

Email address:

NDIS plan details, funding & service requests

NDIS reference number:

NDIS plan start date

NDIS plan end date:

Funding area (if known):

My funding is:

NDIA Managed

Plan managed

Self-managed

I'm not sure

Plan manager name:

Plan manager phone number

Plan manager organisation

Email to send invoices to:

Risk details & Support Plan

Please complete this section if this is your first time signing up to Day Trips & Groups, or if you have not filled this out in the last six months.

Dietary requirements:

Psychosocial disability and other relevant medical history/diagnoses/allergies:

Are there any risks associated with supporting the participant?

'Risk' means anything that may impact the participant or those around them, e.g. animals, weapons, alcohol/drug use, aggression, suicide/self-harm, legal orders, etc.

Does the participant have any conditions or limitations that may impact their ability to participate in activities? If so, please provide as much information as possible below:

NDIS plan goals:

Additional comments/requests/info to be added:

Referrer details (if not listed above)

The referrer has already been listed above

Referrer relationship to participant:

Self-referred

Support coordinator

Carer

Other

Full name

Organisation

Email address

Phone number

Emergency contact:

Full name

Phone number

Email

Support Coordinator details

Full name

Phone number

Email

Organisation

Thanks for referring to Alacrity Health! before you finish, we have optional questions to improve this form for you.

Why did you choose Alacrity Health?

Is there anything we can do to improve this form/make it more accessible for you or others?

Day Trips & Groups Referrals & Sign Up

Services

Details of person completing this form

Participant details

Primary contact details

NDIS plan details, funding & service requests

Risk details & Support Plan

Referrer details (if not listed above)

Emergency contact:

Support Coordinator details

Thanks for referring to Alacrity Health! before you finish, we have optional questions to improve this form for you.