Kids Aqua Skills Group Plympton Park - January 2025

Registration & Service Agreement

Come and make a splash with us this school holidays!

Autism SA’s Kids Aqua Skills School Holiday Program is a fun and skill-building group program run by Occupational Therapists and Speech Pathologists for children aged 3-8 years old.

The program will consist of a ratio of 4 therapists to 4 participants, focusing on developing skills related to water familiarisation, buoyancy, mobility, and water safety. These activities also include opportunities to target communication, language, play, and social skills in the water.

Participants in Kids Aqua Skills have the opportunity to engage with their peers in a facilitated group environment with additional support for participants that require 1:1 support.

The program is delivered as a program of support and sessions are run over 3 consecutive days for 45 minutes each, with an additional 15 minutes allocated to each group to debrief with parents/caregivers and complete documentation requirements.

Location: Proswim Swimming Centre, 586 Marion Road, Plympton Park 5038

Date: Tuesday 21st January 2025, Wednesday 22nd January 2025 and Thursday 23rd January 2025

Time: 1 hour sesssions will be running between 12:30pm and 2:30pm

Duration: 45-minute session x 3 sessions (over Tuesday to Thursday)

Cost: $619.47 ($581.97 plus $37.50 out of pocket pool hire fee).

Please note that the submission of this form does not guarantee entry into this group. The first 12 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 *

Parent/Caregiver last name *

Participant birth date *

Email Address *

Phone number: *

Preferred Pronouns

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

Other, please specify below

About my child

What is your child'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 your child's diagnosis

How does your child communicate? *

Please advise what AAC device your child uses

Other, please specify

How does your child cope currently in noisy environments? *

Doesn’t appear botheredWill appear uncomfortable or upsetWill use behaviours to show frustration/dysregulationWill abscond (leave a designated area)Other

Other, please specify *

Does your child have a fear of water? *

YesNo

Does your child have any specific interests that they enjoy? *

YesNo

If yes (please describe interests below) *

What is your child’s previous experience with water? *

Aquatic TherapySwimming LessonsCasual SwimmingNo Experience

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 your child’s involvement in this group?

Is there any other information you would like us to know about your child?

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 *

NDIS Number *

NDIS Plan Dates *

Please upload a copy of your NDIS plan

Browse

How much will it cost?

Full program price is $619.47 ($581.97 plus $37.50 out of pocket pool hire fee).

The cost of the program is in line with NDIS rates plus a $37.50 (GST inclusive) out-of-pocket pool hire charge.

Please note if using NDIS funding, this will come from your Improved Daily Living Budget (excluding pool hire fee).

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 event/orfor use in Autism SA 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 agree to the total cost for 3 sessions of Aqua Skills as noted above *

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

I agree to the total out of pocket cost of $37.50 for the pool hire charge. I understand that I will be invoiced for this seperately and that this is not claimable via NDIS funding. *

I acknowledge that toileting needs whilst at the pool are a parent/caregiver responsibility. If the participant is bladder or bowel incontinent, swimming nappies or an appropriate continence pad is worn at all times whilst in the water. *

I agree to not attend this group if the participant has had any of the following within the time frames below:

Infectious diseases such as measles, chicken pox, rubella, mumps, hepatitis etc. (until advised by a medical practitioner that the infection is no longer contagious)
Ear, throat, eye, respiratory or urinary tract infections (until advised by a medical practitioner that the infection has resolved)
Vomiting or diarrhoea (48 hours after symptoms have ceased)
Tinea or Plantar warts (until treatment has commenced)
Children with grommets have sought seek medical advice before commencing

*

Captcha *

Please sign *

Draw signature|Type signatureClear