Member Enrollment - Life Your Way

Client Name*

Prefix Client First Name Client Surname

Email For Booking Confirmations*

Enter Email Confirm Email

Website Username*

Please consider whether this is best to the the client themselves or a parent/guardian/carer. This email address will be the primary one we communicate to.

Website Password*

Include at least 1 capital letter, 1 number and 1 symbol.

Enter Password Confirm Password

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Region
Penrith
Gold Coast

Additional Client Details

Client Address*

Street Address Address Line 2 Region State Post Code Country

Client Date of Birth*

DD slash MM slash YYYY

Client Phone Number

Client Can Be Contacted Directly*

Yes

Primary and Emergency Contact Information

Primary Carer*

Prefix First Last

Primary Carers Address

Address of primary carer if different to the client

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Carers Phone*

Primary Carers Email*

Enter Email Confirm Email

Relationship to Client*

Emergency Contact

Please provide details if emergency contact is not Primary Carer or you wish for a second person to be added as a emergency contact.

Prefix First Last

Emergency Contact Phone

Emergency Contact Email

Emergency Contact Relationship to Client

Plan Management Information

Plan Management Type*

Plan Management Company*

Plan Management Phone*

Plan Management Email*

Best Email For Invoices*

NDIS Number*

NDIS Plan

The government now only permits funding claims alligned to goals within a clients plan. To help us facilitate a enagement strategy for you with us please upload a copy of your current NDIS plan.

Max. file size: 16 MB.

Does the client have a Support Coordinator?*

Yes

Support Coordinators Company Name

Individuals Name

First Last

Support Coordinators Phone Number

Support Coordinators Email

Support Coordinators Website

About the Clients Disability

Clients Diagnosis*

Mild Intellectual Disability

Moderate Intellectual Disability

Severe Intellectual Disability

Autism

Down Syndrome

ADHD

ODD

Other

Companion Card

Please upload a copy of your companiion card if you have one

Max. file size: 16 MB.

Concession Card

Please upload a copy of your Concession Card if you have one.

Max. file size: 16 MB.

Social and Behavioural Information

Can the client read?*

Yes

Can the client write?*

Yes

Can the client tell time?*

Yes

Can the client follow basic instructions?*

Please come here. Get your things. We're going here now.

Yes

Is the client likely to avoid participation in group activities?*

Yes

Does the client have any fears or phobias?*

Yes

What are they?

Are there particular situations that the client may find particularly stressful?*

Yes

What are they?

Is the client confident handling cash?*

Yes

Can the client use a debit/credit card?*

Yes

Does the client have a tendancy to wander off?*

Yes

Is the client confident in crowded situations?*

Yes

Does the client require assistance with toileting?*

Yes

Do you wish to provide any further information on the above questions?

Physical Ability

Does the client have any physical mobility issues?*

Yes

What are they?

Can the client walk unaided on and off through the day?*

Yes

Can the client walk comfortably on uneven surfaces?*

Yes

Can the client stand for extended periods of time without needing to sit?*

Yes

Can the client walk unaided for extended periods of time?*

Yes

Can the client walk with a backpack on their back and not risk losing their balance?*

Yes

Can the client walk up and down hills without losing their balance?*

Yes

Can the client lift baggage to place it on their bed, luggage carousels and in/out of vehicles?*

Yes

Do you wish to provide any further information on the above questions?

Travel and Overnight Experience

Does the client usually sleep with the lights on?*

Yes

Would the client find it acceptable to share a room with another client overnight*

They would ofcourse be the same sex and in separate beds.

Yes

Does the client require checks throughout the night?*

Yes

Does the client require assistance with showering?*

Yes

Does the client require help with choosing appropriate clothes?*

Yes

Does the client require assistance with basic grooming?*

Yes

Has the client spent time away from the primary care giver overnight previously?*

Yes

Do you wish to provide any further information on the above questions?

Health and Medical Information

Doctors Name*

First Last

Doctors Practice*

Doctors Phone Number*

Health Fund

Health Fund Name

Health Fund Policy Number

Immunisation History

Is the client immunised?*

Measles

Mumps

Rubella

Triple Antigen

Hep B

COVID19

Other

Please upload copies of immunisation certificates

Drop files here or

Max. file size: 16 MB, Max. files: 5.

Allergies and Medications

Does the client suffer from any of the following?

Asthma

Diabetes

Epilepsy

Anaphylaxis

Will the client be bringing a Epi pen with them?

Yes

No it's not neccessary

Does the client have a communicable disease?

Yes

What is it?

Current Medication

Medication Name

Dose

Frequency

Time to be Administered

Details of Food Allergies

Details of Non-Food Allergies

Details of Specific Dietary Requests

Acknowledgements

Sunsmart Agreement*

I understand and agree that the staff may need to apply sunscreen to the client as and when neccessary; however I/We undertake to supply the client with an adequate amount of sunscreen and standard protective garments for them to use in accordance with sun smart guidelines.

I agree to the Sunsmart Policy.

Medical Treatment*

We the undersigned confirm that In the event of such an emergency requiring immediate medical attention, I/we the undersigned give permission for a legally qualified medical officer, registered to practice medicine in the country of the emergency to provide treatment, perform tests or administer medication to the client.

I agree to this treatment policy.

Paracetamol/Ibuprofen Consent*

We the undersigned confirm that the tour participant may be administered Paracetamol and/or Neurofen for the treatment of minor ailments if required (dose as per packaging and used strictly as directed).

I agree to this medication policy.

Accuracy of Information*

I/We the undersigned confirm that the information provided in this application and booking form pertaining to the client as completed in this form are true and correct and any contra-indications or concerns regarding administration of the medication and general health care have been detailed.

The information I have provided is true and correct.

Medical Expenses*

I/We acknowledge and assume all financial responsibility for all expenses that may be incurred for the medical treatment, ambulance transport and medications.

I agree with this expense policy

Establishment Fee*

I/We the undersigned confirm that we give permission for Life Your Way to claim the NDIS Establishment Fee 04_049_0136_1_1 when the criteria is met in accordance with the NDIS Price Guide.
Read more on the Establishment Fee HERE

I agree with Life Your Way claiming the Establishment Fee

Policies

Image Release*

I consent to Life Your Way to capture, use, and share images (photographs, videos, digital media) of myself/my dependent for the following purposes:

Use on the Life Your Way website
Sharing on Life Your Way social media platforms (e.g., Facebook, Instagram)
Local sharing within the community (e.g., newsletters, community boards, event promotions)
I understand that these images will be used to promote the activities, programs, and successes of Life Your Way and may be viewed by the public.

I also understand that:

I have the right to revoke this consent at any time by providing written notice to Life Your Way.
Life Your Way will make reasonable efforts to remove my images from future materials upon receiving a revocation notice, but may not be able to remove images already published.
This consent is valid for one year and will need to be renewed annually during the enrollment process.

I agree to the image release policy.

Code of Conduct*

lifeyourway.au/code-of-conduct

I agree to the Code of Conduct.

Activity Expenses*

lifeyourway.au/activity-expenses

I agree to the Activity Expenses policy.

Non Face-To-Face Charges*

lifeyourway.au/non-face-to-face-costs

I agree to the Non Face-To-Face policy.

Cancellation Policies*

lifeyourway.au/cancellations

I agree to the Cancellation policies.

Signature*

Enrollment Form

Additional Client Details

Primary and Emergency Contact Information

Plan Management Information

About the Clients Disability

Social and Behavioural Information

Physical Ability

Travel and Overnight Experience

Health and Medical Information

Health Fund

Immunisation History

Allergies and Medications

Acknowledgements

Policies

Contact Us

Office Hours

Fine Print

Programs