New Enrolment Form

D.O.B *

Person’s name *

Parent/Guardian names *

Residential Address *

Email *

Phone Number *

Accommodation Services (if applicable) *

Address *

Daytime Contact No. *

Accommodation Email *

Trial Day Required
YesNo

Does Participant Require Transport?
YesNo

Type of Disability and Level of Support Needs (medium, high etc) *

If Known, How Will You Pay for the Service? *

DCSI FundingNDIS FundingSelf Funding

No Of Days Requested *
MonTueWedThuFriSatSun

What are his/her special interests?

What activity does he/she like doing?

What are his/her current goals?

What other goals would he/she like to achieve?