YLOT Holiday Buddies Program

Participant's Name: *

First

Last

Date of Birth: *

Age:

Parent/Guardian Details:

Name: *

First

Last

Address: *

Address L

City: *

State: *

Postcode: *

Phone Number: *

Email: *

Workplace (if applicable):

Child's School: *

Class: *

Teacher Name: *

Teacher's Email

I give permission for YLOT to contact my child’s class teacher to discuss learning goals.

NDIS Number: *

My child’s NDIS plan is: *

Self Managed
Plan Managed
NDIA Agency Managed

My child has sufficient funds in their NDIS plan to cover the holiday program *

Yes
No
Unsure (please contact your plan manager or YLOT for a quote if unsure)

Indicate which NDIS Plan category to charge the participant's program fees: *

Core Supports (social & community participation) 04_104_0125_6_1
Capacity Building (Social and Community Participation) 09_009_0017_6_3
Capacity Building (Community Participation Activities) 09_011_0125_6_3
Capacity Building (Improved Relationships) 11_024_0117_7_3
Capacity Building (Improved Daily Living) 15_037_0117_1_3
Unsure which section (please contact your plan manager if unsure)
No Plan. Private fee-for-service (non NDIS)

Plan Manager: (if applicable)

First

Last

Plan Manager Email:

Plan Manager Phone Number:

Support Coordinator: (if applicable)

First

Last

Support Coordinator Email:

Support Coordinator Phone Number:

Emergency Contact 1

Name: *

First

Last

Relationship: *

Phone Number: *

Emergency Contact 2

Name:

First

Last

Relationship:

Phone Number:

Session Details:

Please note all days requested may not be confirmed due to a high volume of bookings. Booking requests will close two weeks before starting date-

I am requesting my child attend on the following days.: *

The participant uses a wheelchair: *

Yes
No

The participant has a behaviour management plan: *

Yes
No

The participant has 'regulated restrictive practices' authorised in an NDIS approved behaviour management support plan: *

No
Yes, please list Type/s of Restrictive Practice:

Type/s of Restrictive Practice authorised:

The participant has a meal management plan: *

Yes
No

The participant has a medical action plan (eg Asthma, seizure management, etc): *

Yes
No

The participant has an Individual Education Plan (IEP) or Learning Plan (LP) at school: *

Yes
No

The participant has a manual handling plan: *

Yes
No

I give permission for my child’s plans above to be shared with YLOT by my child’s school, to assist with individual planning for support.

I have included a copy of the above plans.

Please attach copy of plans here, if you have them:

Drag & Drop Files, Choose Files to Upload

Please list any allergies: *

Please list any medications taken during the day (note If the participant needs medication during the program you will need to provide us with a signed medication chart from their GP):

Please list any additional info:

Holiday Program Participant Profile

To enable our staff to best meet the participants needs we ask that you complete the following questions for us to be able to create a Profile for staff to assist in supporting the participant.

Please attach a photo of the participant

Drag & Drop Files, Choose Files to Upload

What is important to the participant?

What do people like and admire about the participant?

What does the participant like doing? *

Things the participant doesn’t like: *

How does the participant communicate? If non-verbal what type of AAC device do they use? *

How can we best support the participant (including toileting information): *

Please give any other information that will enable us to best support the participant at The Holiday Program, including diagnosis information if happy to share:

Media Consent

We love capturing moments of fun and connection during our holiday activities! Please let us know your preferences regarding photos and videos of the participant: *

Yes, I consent to the participant being photographed and/or filmed, and for these images/videos to be shared on our social media and website.
No, I do not consent to any media of the participant being taken or shared.
No media for publishing, but I would like to see photos of the participant privately (e.g., shared directly with me but not posted publicly).

NOTE: Photos will be taken and shared occasionally, but not necessarily every day.

Declaration:

I acknowledge that: • These records will be managed by YOUNG LEADERS OF TASMANIA (YLOT) only. • Information within these records will be shared with specific staff members within the organisation to allow them to carry out the intake assessment. • If the participant is offered YLOT's services and they accept, this information will also be used to carry out the initial assessment and for service planning, development and delivery. • The participant and their representative can ask to see the records and receive a copy. • Records are archived for a set period according to Privacy and Confidentiality Policy and Procedure. • All information obtained will be kept confidential. • This information will be used to set up the Service Agreement with YLOT and the Participant Assessment and Support Plan if the participant is offered YLOT's services and they accept. • A signed Service Agreement is required to start receiving YLOT's supports and services. • A Service Agreement will be sent to the participant for signing prior to the appointment of the initial assessment. This is a legal requirement by NDIS. • The Service Agreement is signed off by both the participant and/or their representative and YLOT. I confirm that: • I understand I can get further information about how YLOT handles my personal information from the Privacy and Confidentiality Policy and a copy of this policy. • I understand I can withdraw or change my consent to share information and/or my permission for a third party to act on my behalf at any time. • I confirm the information provided in this form is complete and correct. • I give my consent to YLOT to use the participant’s information for the purposes outlined above. • I understand giving false or misleading information is a serious offence. • I understand this information is protected by law and can only be given to someone else where Commonwealth law allows or requires it or where I give permission. You can find out more about how we collect, use and disclose your personal and sensitive information on our Privacy and Confidentiality Policy.

Signed (Type name) *

By typing my name above, I acknowledge that I am signing this form. This typed name is intended to serve as my signature.

Date: *

Expression of Interest

Parent/Guardian Details:

Emergency Contact 1

Emergency Contact 2

Session Details:

Holiday Program Participant Profile

Media Consent

“I wanted to understand how different life is for people living with disability and also to see how we are all the same”

LEADERSHIP THROUGH PERSONAL GROWTH