NDIS Registration - Canberra Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Participant Name *Phone *Email *Date Of Birth *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodePlease select programs belowHoliday Program Week 1Movie Trip (Monday 30/12/2024)Bowling/Timezone (Monday 31/12/2024)PUBLIC HOLIDAY - NO ACTIVITY (Wednesday 01/01/2025)Horse Riding (Thursday 02/01/2025)Holiday Program Week 3Ninja Park (Monday 13/01/2025)Aqua Park (Tuesday 14/01/2025)Reptile Zoo (Wednesday 15/01/2025)Interactive Gaming (Thursday 16/01/2025)Holiday Program Week 5PUBLIC HOLIDAY - NO ACTIVITY (Monday 27/01/2025)Obstacle Course (Tuesday 28/10/2025)Jungle Golf (Wednesday 29/01/2025)Powerkart Raceway (Thursday 30/01/2025)Holiday Program Week 2Aquatic Centre (Monday 06/01/2025)Flipout (Tuesday 07/01/2025)Lake Burley Cruise (Wednesday 08/01/2025)Treetops Adventure (Thursday 09/01/2025)Holiday Program Week 4Questacon (Monday 20/01/2025)Kayaking (Tuesday 21/01/2025)Movies (Wednesday 22/01/2025)Zone 3 VR / Laser Tag (23/01/2025)Parents/Guardian Name (if applicable)NDIS Plan Start Date * NDIS Number *NDIS Plan End Date *Funding Management *Choose Funding managementNDIA ManagedSelf ManagedPlan ManagedFill in Your Plan Manager Details (if applicable)I give consent for photographs and/or videos to be published via various forms of media such as Social media, Website, Organisational or promotional material and Education and training purposes *Please SelectYesNoI Give Permission for Me/My Child to be Picked up And Dropped by CORE ASSIST DISABILITY SERVICES *Please SelectYesNoPlease List Any AllergiesPlease List Any Medications (name, date and time)Enter The Full Name Which Serves as The Electronic Signature for This DocumentSubmit