8-Week Group Based Evening Cooking Activity for Kids Referral Form 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 Evening Cooking Program Week 1: Monday 13th October 2025 Meat Pies & Sausage Rolls Week 2: Monday 20th October 2025 Mini Cob Loaves Week 3: Monday 27th October 2025 Mummy Dogs & Spider Choc Cakes Week 4: Monday 3rd November 2025 Beef Stroganoff & Rice Week 5: Monday 10th November 2025 Apricot Chicken & Rice Week 6: Monday 17th November 2025 Pizza Pockets with Garlic Bread Week 7: Monday 24th November 2025 Mac 'n' Cheese Bake & Garlic Bread Week 8: Monday 1st December 2025 Potato Salad & Christmas Dessert Week 9: Monday 9th December 2025 Curry Sausages & Rice Additional Information FOOD & ALLERGY DETAILS (if applicable) Dietary Requirements: Food Allergies Any other allergies: TRANSPORT REQUIREMENTS Does your child require transport to IDA's Group Based Evening Cooking Program for Kids? Yes No Unsure at time of referral Please select the weeks your child requires transport Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 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’.
