Adult Cooking Group - Elizabeth

Registration & Service Agreement

The adult cooking group is a program for individuals aged 18 years and above that supports the development of food and kitchen safety skills, basic functional cooking skills, planning and problem-solving skills (executive functioning) and social communication opportunities in a group setting. The group will support individuals to participate in a range of different cooking experiences whilst supported by Occupational Therapists and Speech Pathologists

The group will run for 3 days from Monday 15th April to Wednesday 17th April 2024. Each session includes 1.5 hours face to face and 30 minutes non face to face support.

Location: Autism SA Northern Hub, Elizabeth (1/57 Elizabeth Way, Elizabeth)

Date: Monday 15th April to Wednesday 17th April 2024

Time: Sessions will be running between 1:30pm - 3pm (face to face component)

Duration: 1 hr and 30 minute face to face session plus 30 mins non face to face each day.

Full Program Cost: $1163.94 plus $10 out of pocket cost.

Please note that the submission of this form does not guarantee entry into this group. The first 6 eligible participants to complete this form will secure places in the program and the remainder will be prioritised for last minute cancellations. Our team will be in touch with you in the coming weeks with more information to confirm these details.

Participant details

Participant first name *

Participant last name *

Parent/Caregiver first name (if applicable)

Parent/Caregiver last name (if applicable)

Participant birth date *

Email Address *

Phone number: *

Preferred Pronouns

He/Him/HisShe/Her/HersThey/Them/TheirsOther (please specify below)

Other, please specify below

About the participant

What is the participant's diagnosis? *

No diagnosisAutism Spectrum DisorderPhysical DisabilityHearing/Vision impairment (please advise in comment box below)Seizure/Heart Condition (please advise in comment box below)ADHDOther (please advise in comment box below)

Please advise the participant's diagnosis *

How does the participant communicate? *

Please advise what AAC device the participant uses

Does the participant frequently display any of the below behaviours? Please tick which are relevant. *

Other, please specify

Does the participant have any specific interests that they enjoy? *

YesNo

If yes (please describe interests below) *

Does the participant have any allergies? *

YesNo

If yes (please describe allergies below)

Do they have an Oral Eating and Drinking Care Plan (OEDCP), if yes, please upload here:

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I confirm that the description of the group above match the participant's NDIS goals and what they would like to get out to the group *

Is there anything specific that you are hoping to achieve from the participant's involvement in this group?

Is there any other information you would like us to know about the participant?

Registration/Service Agreement

Please complete and submit this form to register for the program. Once complete, your answers to the below questions will form your Service Agreement. You will be asked to agree to our Terms and Conditions and the costs of the program. You will receive a copy of your answers once submitted.

Please indicate whether you will be funding the group by NDIS or Fee for Service (FFS) *

NDISFee For Service

I am *

Plan ManagedSelf ManagedAgency Managed

I give approval for a Service Booking to be made for the value of the program *

Plan Manager Name *

Plan Manager email address *

NDIS Number *

NDIS Plan Dates *

Please upload a copy of your NDIS plan

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How much will it cost?

Full program price is $1163.94 plus an out of pocket fee of $10.

Each session includes 1.5 hours face to face and 30 minutes non face to face support.

The cost of the program is in line with NDIS rates.

Please note if using NDIS funding, this will come from your Improved Daily Living Budget.

The relevant policies are:

T&C's Autism SA NDIS

T&C's Autism SA FFS

Photographic/Video Release Authority

I grant Autism SA, its representatives, employees and suppliers the right to take/use photographs/videos of myself and/or my child/children and my property during attendance at the above-identified eventfor use in marketing collateral such as annual reports, publicity materials, advertising, social media and web content.

Response *

Yes, I grant Autism SA the rights aboveNo, I do not grant Autism SA the rights above

I have read and accept the Terms and Conditions of this service, including the cancellation policy *

I have adequate funding available under my Improved Daily Living Budget, and this does not expire during the dates I wish to book *

Captcha *

Please sign *

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