8-Week Group Based Activity for Adults 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 GUARDIAN/PLAN NOMINEE INFORMATION Only complete if applicable First Name Last Name Relationship to Participant: Phone Email (required) 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 2 School Holiday Period Week 1: Friday 18th July 2025 Rock Painting Week 2: Friday 25th July 2025 Mason Jar Lights Week 3: Friday 01st August 2025 String Based Art Week 4: Friday 08th August 2025 Candle Making Week 5: Friday 15th August 2025 Origami Making Week 6: Friday 22nd August 2025 DIY Bath Bombs Week 7: Friday 29th August 2025 Dream Catcher Making Week 8: Friday 05th September 2025 Bracelet Making TRANSPORT REQUIREMENTS Do you require transport to IDA's Group Based Activity for Adults? 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 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’.
