JULY 2024 Sense Holiday Groups & Client Service Agreement - (Programs of Support)

How did you hear about Sense Therapies? *

Participant First & Preferred Name : *

Participant Last Name *

Participant D.O.B *

Pronouns

Primary Carer/Guardian First Name *

Primary Carer/Guardian Surname *

Relationship to Participant *

Second Point of Contact for Participant - Name, Relationship to Participant & Phone Number *

Street Address *

Address line one *

City *

State *

Postcode *

Email Address *

Mobile / Phone Number *

Program Activities *

Monday 08.07.2024 - FULL - WAITLIST ONLY - Sense & UOW Science Space - 5yrs + - 10:00am - 1:00pm COST : $320 - ** Location : Meet at UOW Science Space - Squires Way, North Wollongong - NO TRANSPORT PROVIDED **Tuesday 09.07.2024 - FULL - WAITLIST ONLY - Sense Symbio - 5yrs + 10:00am - 2:00pm COST : $420 - **Location : Meet at Symbio Wildlife Park, Lawrence Hargreave Drive, Helensburgh - - NO TRANSPORT PROVIDED **Thursday 11.07.2024 - Olympics - 4yrs + 9:00am - 12:00pm - COST : $300 - **Location : Meet at Shamrocks Rugby Oval, Ocean Park, Woonona - NO TRANSPORT PROVIDED **Friday 12.07.2024 - FULL - WAITLIST ONLY - Sense Hangdog - 5yrs + - 10:00am - 1:00pm COST : $290 - **Location : Meet at Hangdog Climbing Gym, 130 Auburn Street, Wollongong - NO TRANSPORT PROVIDED **

Does the Participant have any SPDR &/or Allergies? *

YesNo

If YES, please specify SPDR &/or Allergies

What would you like the Participant gain from partaking in Sense Therapies Groups? e.g. Social, Gross motor, Emotional Regulation, Sensory Processing skills etc (OR CURRENT PARTICIPANT) *

What would you like our Team to know about the Participant? (OR CURRENT PARTICIPANT) *

Do we need to be aware of any risks? e.g. allergies, seizures, tendency to abscond or become aggressive if the demand is too high? Please note any triggers you are aware of (OR CURRENT PARTICIPANT) *

How can we best support/encourage the Participant? (OR CURRENT PARTICIPANT) *

Please specify any diagnoses, pre-existing &/or new injuries we need to consider in how we plan the sessions *

What are the Participant's goals in relation to this program? (OR CURRENT PARTICIPANT) *Attach copy of current NDIS Plan - if applicable (optional) - see end of this form

Is there anything the Participant would prefer NOT to partake in? *

Funding (as applicable) *

NDIS Plan ManagedNDIS Self Managed Private Health Insurance Self Funded (out of pocket)

NDIS Number - ENSURE DETAILS CORRECT & COMPLETE (If applicable) *

Where to email Invoices : Plan Manager or Participant/Guardian's email *

NDIS Plan Start Date : ENSURE DETAILS CORRECT & COMPLETE (If applicable) *

NDIS Plan End Date : ENSURE DETAILS CORRECT & COMPLETE (If applicable) (If applicable) *

INVOICE PAYMENT PAYABLE ON DAY OF SERVICE PROVISION - applicable to all non Plan Managed Participants either via Direct Debit or TAP & GO *

YESPlan Managed (n/a)

PROGRAMS OF SUPPORT & CANCELLATIONS

All Sense Team Sports, Term Groups & Holiday Activities including Camps are goal orientated, skill based & delivered as Programs of Support.

Programs of Support are delivered as intensive group therapy for a specific period range (no longer than 12 weeks) with a definite start and finish date.

The inclusive period for each Group/Activity offered by Sense Therapies is detailed in the individual Intake Forms, Confirmations & Itinerary communications – prior to commencement.

In acceptance of participation in Programs of Support Participants agree to be charged for the service provided, regardless of attendance/non attendance - as long as the provider had the capacity and delivered the support/activity (or an alternative of the same standard.)

Through utilising the Program of Support model, we can both maximise therapeutic benefit and ensure fair pricing for all Participants. (as per NDIS Price Guide).

NOTE : Programs of Support are not subject to the standard short notice cancellation regulations.

**Programs of Support may be covered under the NDIS Capacity Building OT Group rate, provided the Participant has the allocated funding available.

*

Cancellation/Withdrawal Policy - Sense Holiday Camps

Once the Participant’s inclusion in the Group has been confirmed by Sense Therapies & accepted by the Participant, all stipulations in the Cancellation Policy will apply, regardless of attendance or non-attendance.
Lack of response to any & all confirmationswill not suffice as rejection or withdrawl of the Intake Form completed.
ALL requests forcancellation/withdrawl from confirmed Sense Holiday Camps must be provided in writing via email - prior to the cut off period to avoid cancellation costs.
Participants must notify Sense Therapies of withdrawl fromSense Holiday Camps seven (7) full business days PRIOR to the commencement dates of the agreed commencement date to avoid cancellation costs.
Failure to provide less than seven (7) full business days notice of withdrawal from Sense Holiday Camps will 100% of the Holiday Camp fee.
Participants wishing to exit the Sense Holiday Camps after the commencement/during the inclusive dates will incur 100% of the fee regardless of attendance or non-attendance.

*

PERMISSION TO PARTICIPATE IN SENSE THERAPIES GROUP PROGRAMS

I give permission for the Participant to partake in Sense Therapies Group Program/s.

While I appreciate every effort will be made by Sense Therapies to minimise the possibility of injury, I understand some degree of risk remains inherent in participation in the program/s. I understand I am responsible for remaining present (or close by, as agreed) during sessions & ensuring the Participant's safety.

*

Do you give permission for Images, Video and/or Audio of the Participant be utilised on Social Media and Public Platforms? I understand there is no time or geographical limit on the validity of my permission. *

YesNo

WAIVER OF FINANCIAL GAINS
I understand that the Participant & any associates, including myself, waive all rights to all royalties & related financial related domains. *

Carer Signature: *

Draw signature|Type signatureClear

Date of Submission *