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 4 School Holiday Period Week 1 - Monday 15th December 2025 - Friday 19th December 2025 Monday Morning: Kid's Fishing Monday Afternoon: Movie Monday Tuesday Morning: Petrie Mill Waterpark Tuesday Afternoon: Christmas Themed Art & Craft Wednesday Morning: Brisbane Planetarium Wednesday Afternoon: Kid's Art & Craft - Egg Cres Head Making Thursday Morning: Strathpine Bowling Thursday Afternoon: Kid's Ice-Cream Making Friday Morning: Albany Creek Swimming Pool Friday Afternoon: DIY Kid's Rock Painting 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
