Participant School Holiday Registration Form

General Information

Participant First Name *

Participant Last Name *

School Holiday Program

Hi Everyone,

Please find the information and checkboxes below for the dates and activities of our School Holiday Program. Please Check the boxes of the dates and activities that are suitable for you and also check the boxes if you require Transport by a support worker.

Thank you!

Can you commit to attending the program on the selected dates:

YesNoMaybe

Week One

Glowing Rooms Australia

Will transport by a support worker be required for this date (if applicable)

Location: 1 Emplacement Cres, Hamilton Hill WA 6163

Date: Tuesday 24/09/2024

Time: 10am - 1pm

Details: Immersive Glow Room experience. Packed lunch provided.

Movie Night

Will transport by a support worker be required for this date (if applicable)

Location: Palace Cinemas - (Top floor, Raine Square, 300 Murray St, Perth WA 6000)

Date: Thursday 26/09/2024

Time: TBA

Details: A relaxing evening with a movie chosen by the group. Snacks and drinks provided.

Week Two

Activities at Bentley Hub

Will transport by a support worker be required for this date (if applicable)

Location: Unit 1/21 Catherine St, Bentley WA 6102

Date: Tuesday 1/10/2024

Time: 10am - 1pm

Details: A day of arts, crafts, and games at Bentley Hub. Lunch provided.

Nostalgia box

Will transport by a support worker be required for this date (if applicable)

Location: 69 Plaistowe Mews, West Perth WA 6005

Date: Thursday 3/10/2024

Time: 5:30pm - 8:30pm

Details: A trip to the Nostalgia Box, Australia’s only video game console museum. Participants can explore the history of gaming and try out classic games. Lunch provided.

Bentley Hub - End of School Holiday Party

Will transport by a support worker be required for this date (if applicable)

Location: Unit 1/21 Catherine St, Bentley WA 6102

Date: Friday 4/10/2024

Time: 10am - 1pm

Details: Celebrate the end of the school holidays with a party at Bentley Hub. The day will include games, music, and party snacks or BBQ.

Transport

Transport is available if needed. Please find the checkboxes above if you require transport for the dates you have selected.

Note: Pick-up and drop-off services are offered at an additional cost, which can be claimed under your NDIS plan.

Consent

Program Eligibility:The School Holiday Program is specifically designed for teens with disabilities. However, acceptance into the program is subject to evaluation by Life Purpose Australia & Dynamic Support WA to ensure that the program is a suitable fit for the participant's needs.
Communication: By providing your contact details, you consent to being contacted by Life Purpose Australia & Dynamic Support WA for the purpose of program coordination, scheduling, and updates related to the School Holiday Program.
Confidentiality: Life Purpose Australia & Dynamic Support WA are committed to protecting your privacy. Personal information
provided on this form will be used solely for program-related communication and coordination and will not be shared with third parties without your explicit consent.
Photography and Media: You acknowledge that photographs or videos may be taken during program activities. Life Purpose Australia & Dynamic Support WA reserves the right to use these images for promotional and marketing purposes. If you have concerns regarding the use of your or your child's image, please notify us in writing.
Program Changes: Life Purpose Australia & Dynamic Support WA reserves the right to make changes to the program schedule,
format, or location as deemed necessary. Participants will be notified of any significant changes in a
timely manner.
Health and Safety: Participants are responsible for disclosing any relevant health information, including specific needs related to disabilities, that may impact their participation in program activities. Life
Purpose Australia & Dynamic Support WA will take reasonable steps to accommodate and ensure the health and safety of
participants during program sessions.

By submitting this form, you confirm that you have read, understood, and agreed to the terms outlined in
this disclaimer. *

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