Mate, Date, or Fake - Elizabeth

Registration & Service Agreement

A program delivered by a multi-disciplinary team of allied health professionals for autistic children aged 13 to 17, focusing on encouraging healthy relationships and connections with others, with a focus on cyber safety when interacting with people online. The program aims to empower with the knowledge and skills required to navigate relationships in the digital age safely.

Core program goals: Foster healthy relationships, provide education on cyber safety, and equip children with skills to navigate online interactions.

Date: 23rd of April 2024

Time: 1:00pm to 4:00pm

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

Duration: 3 hour session and 15 minutes non face to face

Full Program Cost: $362.25

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 4 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 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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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. *

If '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)

Additional Comments

How does the individual manage being in a room with up to 11 other peers and 6 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

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

Additional Comments

Does the participant 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 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 *

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 $362.25

Each session includes 3 hours face to face and 15 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

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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