Participant Registration - ACG Support Services

Participant Registration

please enter all your details to help us get you started.

ADDITIONAL INFORMATION

Name, email and contact phone.

PARTICIPANT DETAILS

FIRST NAME

PARTICIPANTS first name only

LAST NAME

PARTICIPANTS last name only

STREET ADDRESS

PARTICIPANTS street number and name

SUBURB

PARTICIPANTS Suburb

MOBILE NUMBER

PARTICIPANTS phone number otherwise Guardian no. Leave the first 0 off the number

PARTICIPANTS email address if applicable, otherwise Guardian email address

DATE OF BIRTH

dd-mm-yyyy

EMERGENCY CONTACT * if Different to above

Best person to contact in an emergency

GUARDIAN OR AGENT DETAILS

if applicable

RELATIONSHIP TO PARTICIPANT

Eg, Mother, Father, Legal Guardian, Support Coordinator etc.

GUARDIAN/AGENT FIRST AND LAST NAME

Please enter full name, first and last name.

GUARDIAN/AGENT PHONE NUMBER

Please enter parent, guardian or agent phone number.

GUARDIAN/AGENT EMAIL

Please enter Guardian, Parent or Agent email address.

PARTICIPANT HOBBIES AND INTERESTS

We try to match participants with their Support Workers who have similar interests. Please tick as many as you like.

OTHER_INTERESTS

Other interests or activities you may like to try.

DISABILITY INFORMATION

This section helps us understand your support needs, your disability, and your current NDIS plan details so we can ensure our services are the right fit for you and aligned with your funding.

Enter your NDIS NUMBER

This is can be found on your Plan

PLAN START DATE

dd-mm-yyyy

PLAN END DATE

dd-mm-yyyy

DESCRIBE YOURSELF AND YOUR PERSONALITY

It can be how someone else see's you.

WHAT ARE YOU LOOKING FOR IN YOUR SUPPORT PERSON?

Could be personality, experience, avaiiability and anything else.

YOUR DISABILITY

DISABILITY INFORMATION

Please explain how your disability affects your day to day life.

BEHAVIOURS OF CONCERN

Are there any Behaviours of Concern that we need to know about.

OTHER INFORMATION

SHIFT PREFERENCE

Please be as flexible as you can. This helps us find the right person for you.

HOW IS YOUR PLAN MANAGED?

Self Managed

Plan Managed

NDIA Managed

If you are NDIA managed we are not offer you services. Please contact our office.

PLAN MANAGER DETAILS

Include accounts email address if known.

SUPPORT COORDINATOR DETAILS

WHICH FUNDING CATEGORY IS APPLICABLE?

0 selected

You can choose more than one.

Enter your MESSAGE

Please ask any questions that you may have or tell us anything we may need to know. .

PRIVACY AND CONSENT

Adventure Care Group prioritises the protection and respect of your privacy. We will solely utilise your personal information for the administration of your account and the provision of requested services.

Your consent is necessary for us to contact you regarding our services and other content that may be relevant to you. Kindly indicate your consent by checking the box. You have the option to unsubscribe at any time.

For more information on our privacy practices, and how we are committed to protecting and respecting your privacy, please review our Privacy Policy on our website.

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I agree to receive your communications and accept the data privacy statement.

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By clicking submit below, you consent to allow Adventure Care Group to store and process the personal information submitted above to provide you the content requested including future correspondence and marketing emails.

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