Capability Care April School holiday Program
Participant Details
Participant full name
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Gender
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Participant D.O.B
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Participant NDIS number
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Participant address
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Any allergies ?
Will the client have any medications with them while on activity
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Yes
No
Name of Medications & time of Medication given?
Do you give consent for Capability Care to Administer the Medications
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Plan manage/self manage email
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Is the participant
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NDIA managed
Self-managed
Plan managed
Program Schedule
WEEK 1
07/04/2025 (Sea Life)
08/04/2025 (Lollipop playcentre)
09/04/2025 (Playful Day)
10/04/2025 ( Super Park)
11/04/2025 ( Arts & Crafts Day)
WEEK 2
14/04/2025 (ZOO)
15/04/2025 (OZ Tenpin)
16/04/2025 ( Jurassic World)
17/04/2025 (Baking Day/Fun Day
Guardian Details
Parent/Gurdian/Nominee full name
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Phone
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Email Address
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Support Coordinator name
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Support Coordinator Email
Signature of the person filling the form
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