Expression of Interest Form – Respite Overnight Program

Thank you for choosing to express your interest in the Amazement Pathways Program – Respite Overnight Program.
Due to the nature of supports that our program can offer, as well as animal welfare and workplace health and safety
reasons we can only accept participants that meet the following criteria:

Minimum 18 years of age
Generally able to manage self-care &; activities of daily living
Fair to good level of fitness, and;
Independent level of mobility

Prospective Participant Details

First Name

Middle Name

Last Name

Participant Address

Address Line 1

Address Line 2

Suburb

State

Post Code

Phone/Mobile

Date of Birth

Parent / Guardian Details (or Preferred Contact Person of the Prospective Participant)

First Name

Last Name

Parent / Guardian Address

Address Line 1

Address Line 2

Suburb

State

Post Code

Phone/Mobile

NDIS Funding Information

NDIS Number

NDIS Plan Type

Self-Managed

Plan Managed

Plan Manager Service Provider Name

Plan Manager First Name

Plan Manager Last Name

Plan Manager Address

Address Line 1

Address Line 2

Suburb

State

Post Code

Phone/Mobile

Preferred Attendance Days

Short Term Accommodation (STA) & Assistance / Respite Care 1:1 Service (24 hour period)

Thursday Night (Thursday 9am – Friday 9am)
Friday Night (Friday 9am – Saturday 9am)
Saturday Night (Saturday 9am – Sunday 9am)

Preferred Dates

Amazement Pathways Program Service Pricing 2023-2024

These support items assist participants to access community, social and recreational activities provided in a group setting in a centre.

These support items can be delivered to individual participants or to groups of participants subject to the rules set out in this NDIS Pricing Arrangements and Price Limits.

Funding Core – Short Term Accommodation and Assistance (including the provision of respite care)

GST is not applicable.

Do you have sufficient funding for this STA respite program in your current plan?

Yes

Proposed Participant Support Details

List some of your personal interests or hobbies

Type of supports required for the proposed participant: Please list – using NDIS categories where possible

What are the proposed participant’s NDIS goals for this plan period? (As per NDIS Plan Goals)

Does the proposed participant have any other special needs / specialised requirements?

Do you have a Behaviour Support Plan?

Yes

Do you have a Behaviour Support Plan? (Yes details)

Does the proposed participant have any known allergies, anaphylaxis or phobias?

Does the proposed participant take regular medications or treatments?

Does the proposed participant have access to and from the venue?

Yes

Vaccine Information

Has the prospective participant received the COVID-19 vaccine?

Yes

1st Covid Vaccine date

2nd Covid Vaccine date

Last Tetanus Vaccination Date

Vaccinated against hepatitis A & B?

Yes

Proposed Participant Signature

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Proposed Participant Parent / Carer / Guardian Signature

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