8-Week Group Based Evening Cooking Activity for Kids Referral Form PARTICIPANT INFORMATION First Name Last Name NDIS Number: Participant Date of Birth 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 Evening Cooking Program Week 1: Monday 21st July 2025 Spaghetti Bolognese Week 2: Monday 28th July 2025 Beef Stir Fry Week 3: Monday 4th August 2025 Butter Chicken & Rice Week 4: Monday 11th August 2025 Beef Pies & Apple Pies Week 5: Monday 18th August 2025 Lasagne Week 6: Monday 25th August 2025 Shepherd's Pie Week 7: Monday 1st September 2025 Banana Bread & Muesli Bars Week 8: Monday 8th September 2025 Chilli Con Carne & Rice Week 9: Monday 15th September 2025 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’.
