PARTICIPANT INFORMATION First Name Last Name NDIS Number: Participant Date of Birth Gender Male Female Transgender Non-Binary Genderfluid Agender Prefer Not to State Other Phone (Parent / Plan Nominee / Legal Guardian) (###) ### #### Email (Parent / Plan Nominee / Legal Guardian) * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Parent(s) Name(s): NDIS PLAN DETAILS NDIS Plan Details NDIS Managed Plan Managed Self-Managed NDIS Plan Start Date MM DD YYYY NDIS Plan End Date MM DD YYYY Plan Management Provider Name (if applicable) Plan Management Provider Phone Number (###) ### #### Plan Management Provider Email Address SUPPORT COORDINATOR DETAILS (if applicable) Support Coordination Provider Name Support Coordinator Name Support Coordinator Phone Number (###) ### #### Support Coordinator Email Address GROUP BASED ACTIVITIES INFORMATION: Term 3 School Holiday Period Week 1 - Monday 22nd September 2025 - Friday 26th September 2025 Monday Morning: Kid's Cooking Monday Afternoon: Kid's Fishing Trip Tuesday Morning: Adventure Treasure Hunt Tuesday Afternoon: Kid's Mini Golf Wednesday Morning: Kid's Playdough Making Wednesday Afternoon: Petrie Mill Water Park Thursday Morning: Movie Thursday Thursday Afternoon: Swimming at Sandgate Swimming Pool Friday Morning: Halloween Themed Arts & Crafts Friday Afternoon: Spinaker Park - Newport Week 2: Monday 29th September 2025 - Friday 03rd October 2025 Monday Morning: Kid's Cooking Monday Afternoon: Kid's Fishing Tuesday Morning: Outdoor Activities Tuesday Afternoon: All Abilities Playland Wednesday Morning: Monster Clay Making Wednesday Afternoon: Osprey House Thursday Morning: Kid's Paper Plane Making Thursday Afternoon: Kid's Art & Craft Friday Morning: Morning Movie Friday Afternoon: Revolution Park FOOD & ALLERGY DETAILS (if applicable) Dietary Requirements: Food Allergies Any other allergies: TRANSPORT REQUIREMENTS Does your child require transport to IDA's Group Based Activities for Children program? Yes No Unsure at time of referral Week 1 - Please select the days your child requires transport Mon AM Mon PM Tue AM Tue PM Wed AM Wed PM Thu AM Thu PM Fri AM Fri PM Week 2 - Please select the days your child requires transport Mon AM Mon PM Tue AM Tue PM Wed AM Wed PM Thu AM Thu PM Fri AM Fri PM ADDITIONAL REFERRAL INFORMATION (optional) Please include any additional information you feel will be applicable REFERRER DETAILS Referral Form Completed by: You have successfully submitted your referral for Inclusive Disability Assist’s ‘Group Based Activities for Children - School Holiday Program’. A member of our dedicated team will be in contact with you, to discuss your referral. Should you have any immediate queries regarding your referral, please don’t hesitate in contacting our office on (07) 3448 6365 or emailing us at ‘ndis@inclusiveassist.org’. IDA Group Based Activities for Children Referral Form
