School Holiday Program 2024/2025

Intake Form

Location *

PaddingtonBanyo

CHILD DETAILS

MissMsMxMaster

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender

MaleFemaleNon Binary

ATSI

AboriginalTorres Strait IslanderNone of the Above

PARENT CONTACT DETAILS

Parent Name *

Mobile Phone *

Email *

Address *

City / Suburb *

State *

Postcode *

Preferred Dates to Attend

Paddington

Monday 16th December 2024Monday 23rd December 2024Monday 13th January 2025Monday 20th January 2025

DIAGNOSES

Do you have any diagnoses for your child? *

If you do not have a diagnosis or diagnoses, what are your concerns?

Does your child attend mainstream school?

What additional supports does your child require at school?

Is your child able to independently look after their needs (ie feeding, toileting, dressing)?

Are there any activities (ie exercise) your child should not perform?

Do you have an approved NDIS Plan?

Do you have an NDIS Plan in place?

YesNo

What is the NDIS number?

What are the plan dates?

Please upload your NDIS goals

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Information regarding this School Holiday Program

Our Create, Play, Thrive school holiday program is designed to provide neurodivergent children with a fun and supportive experience through sensory motor activities and art therapy. Please note the following important information:

This is a drop and go program for children, parents are not required to attend.
Minimum Numbers: The program requires a minimum number of attendees to run. If this number isn’t met, days may be cancelled.
Respectful Behaviour: All children must be courteous and respectful to other participants and staff at all times.
Enrolment Process:

Submitting an Expression of Interest (EOI) does not guarantee enrolment.
Enrolment is confirmed only after payment is made and the service agreement is signed.
We reserve the right to refuse enrolment if necessary.

What to Bring:

A packed nut-free lunch.
A hat.
A water bottle.
Sunscreen should be applied before arriving.
Mobile devices are not allowed during the program but can be kept in bags.

We’re excited to create a safe, enjoyable, and enriching environment for your child to learn, play, and thrive!

Create, Play, Thrive School Holiday Program - Waiver of Liability and Release Form

Acknowledgement of Risk
I, the undersigned, acknowledge that participation in the Create, Play, Thrive program may involve physical activities, including but not limited to sensory motor exercises and art activities. While all reasonable efforts are made to provide a safe environment, I understand that there is an inherent risk of injury or harm in any physical or creative activity.

Release of Liability
In consideration of my child’s participation, I hereby waive, release, and discharge the Neurodiverse Playhouse, its employees, volunteers, contractors, and agents from any and all claims, liabilities, or damages arising out of or connected with participation in the programme.

This waiver includes, but is not limited to, claims arising from:

Accidental injuries during program activities.
Use of any equipment or facilities associated with the program.
Unforeseen incidents during supervised play and creative activities.

Medical Emergencies
In the event of a medical emergency, I authorise program staff to seek appropriate medical assistance for my child. I understand that I am financially responsible for any medical treatment or services provided to my child during such an event.

Please list all allergies *

Emergency Contact Name *

Emergency Contact Phone Number *

Acknowledgement and Agreement
I have read, understood, and agreed to the terms of this waiver. By signing below, I confirm that:

My child is physically fit to participate in this program.
I accept all risks associated with participation.

Signed *

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Dated

HOW WE WORK

At Neurodiverse Playhouse, our approach is deeply focused on understanding your child and your unique goals. The information you provide in this form serves as a vital foundation for tailoring our interventions to best suit your child's needs.

This assessment serves as a pivotal step in our process, allowing us to gather essential information to determine the most suitable stream of therapy for your child. Additionally, it provides us with valuable baselines for intervention, ensuring that our approach is both targeted and effective.

COLLECTION OF DATA STATEMENT

The Neurodiverse Playhouse is an independent practice. You may contact The Neurdiverse Playhouse by writing to Neurodiverse Playhouse, 101 Turbot Street, Brisbane 4000 or by emailing letsplay@neurodiverseplayhouse.com.au. You have the right to gain access to the information held by The Neurodiverse Playhouse about you. Our Privacy Policy (available upon request) contains information on how you may request access to, and correction of, your personal information and how you may complain about a breach of your privacy and how we will deal with such a complaint.

Collection of Client information disclosure of client information:

The Neurodiverse Playhouse needs to collect information about you and your child for the primary purpose of providing quality treatment.

In order to fully assess and treat you and your child, we need to collect some personal information from you.

This information will also be used for the administrative purposes of running the practice such as billing you or through an insurer or compensation agency.

Information will be used within the practice for handover if another practitioner provides you with assistance.

Client information is stored securely and only practice staff has access to it.

The Neurodiverse Playhouse takes all reasonable steps to ensure that information collected about you and your child is accurate, complete and up-to-date

You may have access to your information on request and if you believe that any of the information is inaccurate, we may be able to amend it accordingly.

The Neurodiverse Playhouse may disclose information regarding assessments or treatment to your Doctor or other health providers only with your consent.

In the case of insurance claims, it may be necessary to disclose information and/or collect information that affects your treatment.

The Neurodiverse Playhouse will not disclose your information to commercial companies, however specific services or product information as supposed suitable for your management, may be forwarded to you by us, unless you instruct The Neurodiverse Playhouse not to forward this type of information.

Your written consent will be obtained at the start of your treatment in order to carry out the above activities. We do not disclose your personal information to overseas recipients.

If you do not provide relevant personal or health information, in part or in full, to The Neurodiverse Playhouse it may result in incomplete assessment. This may impact the following therapy that is provided.

Any concerns that you may have about this statement or about your management can be directed to The Clinical Director, letsplay@neurodiverseplayhouse.com.au

I have read and understand the above *

Parents/Guardian Signature *

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Date *

SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

Patient/ Guardian Signature

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