Moonee Ponds Holiday Programs April 2025

Application Form

Select your preferred location *

Moonee Ponds Clinic - Moonee Ponds

Week: 8, 9, 10 April 2025 Please select

Cooking Up Conversations - Prep - Grade 3 - Group programCreation Station - Grade 4 - Grade 6 - Group ProgramStorytelling - Individual ProgramF-U-N Spells FUN! Literacy Booster - Individual Program

Week: 15, 16, 17 April 2025 - Please select

Dino Discovery! - Preschool Children - Group ProgramMovie Masters - Grades 4 - 6, Group ProgramStorytelling - Individual ProgramF-U-N Spells FUN! Literacy Booster - Individual Program

Section A - Contact Details

Child's Full Name *

Preferred Name

Gender *

FemaleMaleOther

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 2024/25? *

YesNo

Diagnosis (if any)

Does your child know their diagnosis? *

YesNoN/A

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 / Dietary

Does your child have any allergies? *

YesNo

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

Do your child's allergies require the use of 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.

Does your child have any food sensitivities or restrictions, including cultural or religious *

YesNo

Please add details *

Section D - Behaviour

Please add any relevant information to the above

Does your child have any other significant 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

Please describe your child's strengths: *

Is there any other information we should know about your child to help make their Holiday Group 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 - There may be a Gap Payment which you will be required to pay

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.

How did you hear about our Holiday Programs? *

Section F - Declaration and Consent

IMPORTANT!

For any withdrawal from our holiday programs we require 2 business days’ notice prior to the commencement of the program. A$250 cancellation fee applies with less than 2 days’ notice.

This is an application only and does not guarantee a place in the program.

Please Note: If your child is not a current Spectrum Speech Pathology client, they may require a screening assessment to participate in the program. The cost for a screening assessment will be $226 – 45 minute session.

Please check your application to 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 *