Social Buddies

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):

NDIS Number: *

My NDIS plan is: *

Self Managed
Plan Managed (please list details below)
NDIA Managed

I have sufficient funds in my NDIS plan to cover the Social Buddies 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)

Note: Saturday Social Buddies cannot be charged to Capacity Building, only to Core funding

Plan Manager: (if applicable)

First

Last

Plan Manager Email:

Plan Manager Phone Number:

Support Coordinator: (if applicable)

First

Last

Support Coordinator Phone Number:

Support Coordinator Email:

Emergency Contact 1

Name: *

First

Last

Relationship: *

Phone Number: *

Emergency Contact 2

Name:

First

Last

Relationship:

Phone Number:

The participant uses a wheelchair: *

Yes
No
Sometimes

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

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 *

Yes
No

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 a manual handling plan: *

Yes
No

If the participant is still at school...

I give permission for the participant’s support plans to be shared with YLOT by their school, to assist with individual planning. Below is the email address of the participant's teacher so YLOT can contact them directly.

Email address of teacher:

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 administered during the program you will need to provide us with a signed medication chart from the GP):

Please list any additional info:

Social Buddies Program Participant Profile

To enable our staff to best meet the needs and interests of the participant, we ask that you complete the following questions for us to be able to create a Profile for staff to assist in planning the program.

Why would the participant like to participate in Social Buddies? *

Please attach a photo

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? What are their interests? *

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:

Media Consent

We love capturing moments of fun and connection during our programs! 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).

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: *

Thank you for completing this expression of interest. A YLOT representative will be in contact via email or phone in the coming weeks to discuss your application further.

Parent/Guardian Details:

Emergency Contact 1

Emergency Contact 2

Social Buddies Program Participant Profile

Media Consent

“This program has massively developed my understanding of people my own age living with a profound disability”

LEADERSHIP THROUGH PERSONAL GROWTH