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 (tick all appropriate):

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 have developed a connection and made a friend with my buddy”

LEADERSHIP THROUGH PERSONAL GROWTH