NDIS Registration - Melbourne 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 1 Treetops Belgrave (Monday 23/09/2024)Lego Land (Tuesday 24/09/2024)Bowling/Timezone (Wednesday 25/09/2024)Glen Eira Aquatic Centre (Thursday 26/09/2024)Le Mans Go Karts, Laser Tag and VR (Friday 27/09/2024)Holiday Program Week 2Rush HQ (Monday 30/09/2024)What The Putt (Tuesday 01/10/2024)Clip 'n' Climb (Wednesday 02/10/2024)Movies (Thursday 03/10/2024)Online Game - Fortress (Friday 04/10/2024)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
