Participant’s Full Name (required)

Preferred Name (if different)

Date of Birth (required)

Parent / Carer Name (required)

Relationship To Participant (required)

Email Address (required)

Phone (required)

Address (required)

NDIS Number (required)

How Is The Participant’s NDIS Plan Managed? (required)
Plan-ManagedSelf-Managed

If Plan-Managed, provide contact name, organisation, number and email address:

Which funding category would you prefer to use?
Core SupportCapacity BuildingEither / Whichever is most suitable

Which type of Rainbow Roos support are you interested in? (required)
1:1 Private SessionsBabyRoos GroupsMiniRoos GroupsSchool HolidaysOther

Preferred Session Location (required)

Preferred Day and/or Time

Does the participant already attend a Rainbow Roos session? (required)
YesNoIn the past, but not now

Diagnosis / disability

Tell us a little more about your child. Please include anything that may help our coaches provide a safe, enjoyable and successful session.

Does the participant have any medical conditions, allergies or health considerations we should be aware of? (required)

What would you most like your child to gain from Rainbow Roos sessions? (required)
ConfidenceSocial interaction and friendshipsCommunicationGross motor skillsCoordination and balanceStrength and fitnessEmotional regulationIndependenceParticipation in group activitiesSoccer skillsTrying something newHaving fun and enjoying physical activityOther

Are there any specific NDIS goals you would like us to support or be aware of?

Emergency Contact Name & Relationship (required)

Emergency Contact Phone (required)

Is there anything else you would like us to know?

Declaration & Consent (required)
I confirm that the information provided in this form is accurate to the best of my knowledge.
I understand that it is the participant / nominee's responsibility to ensure sufficient NDIS funding is available for services provided.
I give permission for relevant information provided in this form to be shared with Rainbow Roos coaches where required to safely and appropriately support the participant.
I understand that Rainbow Roos may contact me if further information is required before sessions commence.
I give consent for photos and videos to be taken during sessions and used appropriately by Rainbow Roos.