Birthday Party

Registration & Service Agreement

We're having a party and you're invited!

Join a fun, skill-building group of up to 8 autistic children aged 5 - 8 years old. The group is run by a multi-disciplinary team of allied health professionals and focuses on supporting your child to attend birthday parties with their peers.

The Birthday Party program will be carefully designed and facilitated to support social interaction, engagement in party games and sharing of party food within an environment that is supportive of individuals who have associated sensory processing needs.

Come celebrate with us!

Please note that the submission of this form does not guarantee entry into this group. Your responses will be reviewed to ensure clinical suitability of the group and to ensure that appropriate supports can be put in place for your child. The first 8 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.

Service details

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

Duration: 2 hour session and 15 minutes non face-to-face

Full Program Cost: $228.24 (including $10 out of pocket cost for party food and supplies)

I would like to attend the following session(s): *

Tuesday 8th of October, 10:00am - 12:00pm, Autism SA Elizabeth Thursday 10th of October, 10:00am - 12:00pm, Autism SA Elizabeth

Participant details

Participant first name *

Participant last name *

Parent/Caregiver first name *

Parent/Caregiver last name *

Participant birth date *

Email Address *

Phone number: *

Other, please specify below

About the participant

Diagnosis and/or medical conditions (please detail): *

Does the participant have any current care plans? (Such as OEDCP, Continence, Seizure, Anaphylaxis) *

YesNo

If 'yes', which type of plan(s):

Do any of these plans require emergency medication administration (such as EpiPen, midazolam, Asthma Puffer)? *

YesNo

If 'yes', please specify

Please upload relevant care plan/s

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Does the participant have any dietary requirements? *

YesNo

If yes, what are their dietary requirements?

How does your child communicate? *

Please advise what AAC device your child uses

Other, please specify

How does the individual engage in structured group games/play? *

Independently participates in all games (including movement games, question and answer games, role play etc)Engages in any game with support from an adult (e.g. to take turns, to follow instructions)Engages independently but only for preferred activities/activities of their own choiceRequires consistent support from an adult to participate in a group game (i.e. is unsure what to do, experiences challenges with allowing peers to lead)

Note: Based on the information provided, we recommend 1:1 AHA support to enhance the participant's strengths and ensure they achieve the best possible outcomes from the program. To choose this option, tick "Yes" for AHA support further down on this registration form.

Additional Comments

How does the individual manage being in a room with up to 5 other peers and 3 adults? *

Independently manages by acknowledging others personal space and boundaries and allowing others to be around themRequires support to understand others body language and how to respond (i.e. personal space)Able to manage being in the same room for short periods of time with adult support to access a break out room as requiredIs not currently able to be in a room with peers for longer than 5-10 minutes even with adult support

Note: Based on the information provided, we recommend 1:1 AHA support to enhance the participant's strengths and ensure they achieve the best possible outcomes from the program. To choose this option, tick "Yes" for AHA support further down on this registration form.

Additional Comments

How does the individual manage high levels of excitement or over-arousal? *

Independently regulates when excited or overwhelmedIs able to regulate in a group with peers with adult supportBenefits from 1:1 adult support to move away (i.e. into another room) to regulateRequires long periods of time (i.e. 30 minutes – 1 hour) to regulate themselves

Note: Based on the information provided, we recommend 1:1 AHA support to enhance the participant's strengths and ensure they achieve the best possible outcomes from the program. To choose this option, tick "Yes" for AHA support further down on this registration form.

Additional Comments

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

YesNo

If yes (please describe interests below) *

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 *

NDIS Number *

NDIS Plan Dates *

Plan Manager Name *

Plan Manager Email *

Please upload a copy of your NDIS plan

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How much will it cost?

Full program price is $228.24, which includes a $10 out of pocket fee for party food and supplies.

Each session includes 3 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

Additional 1:1 Allied Health Assistant Support

If you feel your child would benefit from one-to-one support during the group program, we can provide an allied health assistant to support your child for the entire duration of the program. Please note this is an additional charge of $173.58 per session they attend.

Would you like to arrange additional 1:1 support for your child? *

No, my child does not require additional 1:1 support from an Allied Health AssistantYes, I would like to add 1:1 support for my child from an Allied Health Professional and am aware this is an additional cost of $173.58 per session.

Duty of Care

Parents are not required to remain onsite for the duration of the program. However, please ensure that you are contactable in the event of an emergency.

Medication:
If your child or the person you support required routine medication administration, we will not be responsible for administering this during group times. Please ensure you are available to administer.

Accident and Incident Process:
Our staff are first aid trained. In the event of an accident, our staff will provide first aid treatment to your child (if required) and document the incident through our incident management system.

In the event of a serious accident, our staff will seek medical assistance and call an ambulance if required. Any costs associated with the ambulance will be invoiced to the parents/caregiver.

Where medical assistance is required, our staff will first seek medical guidance and then contact parents/caregivers.

Food Allergies:

Please be mindful that children in our program may have allergies. Nuts and eggs, including foods containing nut products, are not permitted onsite.

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 for 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 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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