Social Skills Holiday Program 2021

Application Form

Select program *

Select your preferred location *

Moonee Ponds Clinic - Moonee PondsAshwood Clinic - Ashwood

Section A - Contact Details

Child's Full Name *

Preferred Name

Age *

Date of Birth *

Address *

Parent/Carer Full Name *

Email Address *

Home Phone

Mobile *

Section B - Further Information

Did your child attend any of our Programs in 2019/2020 *

YesNo

Diagnosis (if any)

Current School *

Current Grade *

Does your child have an Integration Aide? *

YesNo

If 'yes', how many support hours?

Does your child have any relevant speech or cognitive assessment reports? *

YesNo

If 'yes', please email copies to essendon@spectrumspeech.com.au

What are your child's special interests? *

What skills would you like your child to learn in this group? *

Section C - Health

Does your child have any allergies? *

YesNo

If you answered 'Yes' above, please provide details. *

Does your child's allergies require you to use an Epi Pen? *

YesNo

If ‘Yes’ please ensure your child brings the Epi Pen along to each day of the program. IMPORTANT: Failure to do so will mean your child will be unable to stay for the day’s program.

Section D - Behaviour

Please add any relevant information to the behaviours selected above

Does your child have any other significant behavioural issues? *

YesNo

If 'yes', please provide details below.

Does your child have difficulty with:

Winning and Losing *

YesNo

Sharing *

YesNo

Taking Turns *

YesNo

Following Rules *

YesNo

Is there any other information we should know about your child to help make their social skills experience with us a success?

Section E - Payment Information

The program will be paid using which of the following *

Privately - We will be in contact for payment prior to service.Third Party Agency NDIS Self-Managed - We will be in contact for payment prior to service.NDIS Plan Managed

If you selected Third Party Agency, please provide details of this agency. Agency will be invoiced.

If you selected NDIS Plan Managed, please provide details of your Plan Manager. Plan Manager will be invoiced.

Section F - Declaration and Consent

Please check your application.

Ensure all required sections are filled in & sign below.

Enter your name *

Signature *

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Please use your mouse or your finger on your computer trackpad to sign.

Date Signed *