NDIS Registration - Melbourne Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.LayoutParticipant Name *Phone *Email *Date Of Birth *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodePlease select programs belowLayoutHoliday Program Week 1 Funtopia Maribyrnong (Monday 01/07/2024)The Mystery Room (Tuesday 02/07/2024)Bowling/Timezone (Wednesday 03/07/2024)Glen Eira Aquatic Centre (Thursday 04/07/2024)Auscarts (Friday 05/07/2024)Holiday Program Week 2Luna Park (Monday 08/07/2024)RampFest (Tuesday 09/07/2024)Melbourne Zoo (Wednesday 10/07/2024)Movies (Thursday 11/07/2024)Online Game - Fortress (Friday 12/07/2024)LayoutParents/Guardian Name (if applicable)NDIS Plan Start Date NDIS Number *NDIS Plan End DateFunding 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
