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):

Will you be attending with your own support worker? *

Yes
No (YLOT can arrange for staff to provide support)
Unsure (please contact YLOT if unsure)

If bringing your own support worker, please list their name and mobile number:

If you would like YLOT to provide your support staff, please list your NDIS Number:

My NDIS plan is:

Self Managed
Plan Managed (please list details below)
NDIA Managed (Unfortunately we cannot accept participants in this category at this time)

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)

Plan Manager: (if applicable)

First

Last

Plan Manager Email:

Plan Manager Phone Number:

Emergency Contact 1

Name: *

First

Last

Relationship:

Phone Number:

Emergency Contact 2

Name: *

First

Last

Relationship:

Phone Number:

I use a wheelchair:

Yes
No
Sometimes

I have a behaviour management plan:

I have 'regulated restrictive practices' authorised in an NDIS approved behaviour management support plan

If yes, as an unregistered NDIS provider, YLOT are unable to enforce regulated restrictive practices. Please contact us to discuss further.

I have a meal management plan:

I have a medical action plan:

Please attach copy of plans here, if YLOT is providing your support:

Click or drag a file to this area to upload.

Please list any allergies:

Please list any medications taken during the day (note If you need 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 your needs and interests, 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 you like to participate in Social Buddies?

Please attach a photo

Click or drag a file to this area to upload.

What is important to me?

What do people like and admire about me?

What do I like doing? What are my interests?

Things I don’t like:

How can you best support me (including toileting information):

Please give any other information that will enable us to best support you:

Media Consent

We love taking photos of our young people having fun in our programs. Please outline below if you consent for photographs, videos and media; and for these to be shared on our social media or website. *

Yes, I consent for media
No, I would prefer no media

Signed (Type name) *

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.

Name

“Probably the most significant development of my understanding of people living with a profound disability was not the differences, but rather the similarities.”

LEADERSHIP THROUGH PERSONAL GROWTH

YLOT OFFICE
Suite 5 Bellerive Quay
31 Cambridge Road
Bellerive TAS 7018

PHONE
0428 640 320

EMAIL
hello@ylot.org.au

© 2024 Young Leaders of Tasmania Ltd 
 ABN 96 624 570 510 

We are a registered charity, your donations are tax-deductible and will go directly towards our programs for young people living with disability.