Clinic Group Enrolment

Our expertly designed group programs will help your child learn and generalise skills with their peers. Please complete this form to support us to support your child!

July School Holidays

Game Time (9+)

Thursday 10th July, 11am - 1pm

Music Time (under 9)

Tuesday 15th July, 11am - 12pm

Term 3 Clinic Groups

School Time 1 (Under 5)

Tuesdays 9:30am - 11:00am, commencing 5th August for 6 weeks

Term 4 Clinic Groups

School Time 2 (under 5)

Tuesdays 9:30am - 11:00am, commencing 14th October for 6 weeks

Client Details

Please enter your child's name.

Title

MrMissMaster

First Name *

Last Name *

Date of Birth *

Diagnosis (if relevant) *

Allergies and/or Food Intolerances *

Caregiver/s Name *

Caregiver/s Phone *

Email Address *

Are you a current Family Time client? *

YesNo

Please select a Group Program

When would you like to enrol? *

July School HolidaysTerm 3Term 4

July School Holiday Programs

Game Time (9+) - Thursday 10th July 11am - 12pm, $188.88Music Time (u9) - Tuesday 15th July 11am - 12pm, $188.88

Term 3 Programs

Tuesdays 9:30am - 11:00am, commencing 5th August for 6 weeks

Term 4 Programs

Tuesdays 9:30am - 11:00am, commencing 14th October for 6 weeks

My Child's Needs

My child's strengths/interests are: *

I would like to see my child improve in: *

Things that will help my child to be successful in the group are: *

Payments

I will access the Group Program/s via:

National Disability Insurance Scheme (NDIS)Private

NDIS Funding line

Funding

Improved Daily LivingCore SupportsIncreased Social and Community Participation

Please note which funding line you would prefer for the groups to be funded. You must have this funding in your current NDIS Plan. If not specified or any queries from your Plan Manager, your group will be funded via Improved Daily Living.

Fund Management

NDIS Number (if relevant)

Consents

Authority to Release Information

I herby give my permission for Family Time to access personal details, relevant to my child/ren.

Including any medical information and documentation on file that I have supplied or has been sent on behalf of us and/or said child/ren, including but not limited to Referrals, Letters, Assessments, Diagnosis, Treatment Notes and Recommendations and Funding Arrangements.

I understand that the information will be treated confidentially and if it is published for statistical purposes in any way, it will not identify the child/ren or any other family member of our/my family.

I understand that I may withdraw my consent at any time in the future by giving written notice.

I acceptI do not accept

Photo Consent

I herby give consent for my child/ren to be filmed or photographed within the Family Time clinic or online group programs for the following:

– Programming and planning

– Educational purposes

– Advertising

– Public notices including Television, Website, Social Media, Flyers or Newspaper

I understand that I/we may withdraw this consent at any time in the future by giving written notice.

I acceptI do not accept

Agreement

Group Programs are available subject to interest/enrolments.

Enrolments for groups are limited per group and placement is offered on suitability following completion of the enrolment process. This includes a consultation with the group facilitator.

Missed or cancelled sessions do not attract a refund if less than 7 days notice is provided.

To maximise your outcomes all sessions should be attended for Term Group Programs. There are no additional or hidden costs.

I acceptI do not accept

By electronically signing, I confirm the above information is true and correct

I am unable to sign but consent to this formed being signed on my behalf.

Name

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