New Client Enrolment Form

Enrolment Form

NEW CLIENT DETAILS

First Name

Last Name

Preferred Name

Date of Birth

Do you identify as

MaleFemaleOther

English is the primary Language

YesNo

Cultural background (optional)

ATSI

AboriginalTorres Strait IslanderNone of the Above

CLIENT CONTACT DETAILS

Mobile Phone

Email

Address

Postcode

City / Suburb

State

EMERGENCY CONTACTS (Please list 2 persons)

Name

Address

City / Suburb

Postcode

State

Mobile Phone

Email

REFERRAL / HOW DID YOU HEAR ABOUT US?

Referral Type/ Name

Details

NDIS PLAN

Do you have a current NDIS plan?

YesNo

How is your plan managed?

Self managedPlan managed

NDIS plan number

We are unable to accept NDI A managed plans

If plan managed, please provide the email we should send our invoices to:

CENTRELINK / GOVERNMENT ISSUED CARDS

Do you have a Pension or Concession card?

YesNo

Do you have a Companion card?

YesNo

Companion card number

Do you have an Medicare Card?

YesNo

Card number

Expiry date

Reference number on card

Attendance

Will you be joining us on a regular basis?

YesNo

Please specify which of the following yo are interested in attending: Wednesday cooking, Thursday fitness, Friday and Sunday socials, Trips away.

What date would you like to start attending activities?

SIGNATURE

I confirm the above information I have provided is true, complete and accurate. I acknowledge that I have access to the Cancellation Policy on Explore Social's website and I agree to the policy terms and conditions. *

I have read and agree to Explore Social's Code of Conduct policy. *

I give permission for photos or videos to be taken of me whilst on Explore Social activities which can then be used on social media or advertising. I acknowledge I have the right to decline appearing in photos and videos during any activity that I attend. *

I acknowledge that Explore Social has limited availabilty for each activity and it is my responcibility to respond and confirm my place within the allocated timeframe, to ensure I don't miss out. *

Parent/ Guardian Signature

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Today's Date

Clients Signature

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Today's Date

Thank you for your time!

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