Little Leader name

    DOB

    Contact number

    Email

    Guardian name

    What Year is my Little Leader in?

    What funding method are you using to fund this program?

    If your NDIS Funding is Plan Managed, please advise of the Plan Manager details for Invoicing (including Plan Manager name, email address for invoices, and your child's NDIS Number)

    What school does my Little Leader attend?

    Will your child need 1:1 support within a group environment? (for sensory/emotional/behavioural purposes, or for any specific areas of need, e.g., physical needs, communication support, etc.)

    If you answered 'yes' or 'unsure' to the above question - please outline the nature of support your child may require.

    Disability and Medical Diagnoses?

    Tell us about your child's strengths and interests, including activities that they might be interested in for group activities?

    Tell us about the things that your child finds difficult, or would like to do more easily.

    Is there anything in particular which triggers dysregulation in your child? (e.g. demands, certain sensory input, experiences, concepts or people?)

    Is your child aware of their diagnosis?
    YesNo

    If you answered 'no' to the above question - are you open to your child learning about their diagnosis? This program is ND-affirming, which means that diagnostic concepts and differences in neurology will be discussed, please let us know your thoughts on how we could best address this for your child

    Other Service Providers Engaged with your child (if you have any reports that you feel would be helpful, feel free to send them through).

    Your specific goals for the group program?

    Do you consent LLA to take photos and use images on social media?
    YesNo

    These groups are facilitated by Little Leaders staff, with clinical training, goals, strategies and approaches from Sarah Young - OT from Infinite Possibilities, I understand that Sarah's input in the program is through program development, staff training, and parent training on a weekly basis, all questions regarding this program should be initially posed to Little Leaders staff.
    Agree

    Does your Little Leader have any medical conditions, medication requirements or injuries that we need to be made aware of?

    Does your Little Leader have any dietary requirements?

    In the unlikely event of an accident I will accept the decision of appointed staff in relation to any urgent or immediate treatment required.
    Agree

    I have read and understood the contents of this form and warrant that all the information provided by me is true and correct. I can confirm that I understand that while every due care and diligence will be extended to the child during their participation in the Little Leaders Australia camps/programs and while in the care of appointed coaches, there is risk of physical injury. As the parent/guardian of the Little Leader I voluntarily accept the risk associated with the Little Leaders participation.
    I agree to release, defend, hold harmless and indemnify Little Leaders Australia and their employees and agents from and against any actions, claims, demands, expenses and liabilities however arising from injury, loss or damage arising from my son/daughter's participation in the program.
    Agree

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