Childs Name

    DOB

    Guardian name

    Email

    Contact number

    Is your child a new or returning member?

    What day(s) are you available to attend?

    Which location would you like to register for?

    Do you give permission for LikeMinds staff to transport your child or children in their vehicle?
    YesNo

    Family home address

    Do you consent for LikeMinds to take photos and video and use images and or video footage on social media?
    YesNo

    Disability and Medical Diagnoses

    Does your child have any dietary requirements?

    What funding method are you using to fund this group 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)

    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.

    Please advise if your child has any allergies, intolerances, or chronic medical conditions - particularly any which require additional support (e.g. asthma, anaphylaxis, diabetes, etc.).

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

    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?

    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

    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

    What indoor activities does your child enjoy?

    What outdoor activities does your child enjoy?

    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 generic in nature and if i would like more specific support around my child's neurodivergent profile, I will need to seek individual assessment from an occupational therapist.

    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 LikeMinds program and while in the care of appointed coaches, there is risk of physical injury. As the parent/guardian I voluntarily accept the risk associated with the child's participation.
    I agree to release, defend, hold harmless and indemnify Little Leaders Australia/Infinite Possibilities/LikeMinds 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

    Please make sure you click the submit button:

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