Rooster Tours Registration Form

Participant Details

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address

Residential Address *

Participant Representative & Emergency Contact

First Name

Last Name

Email

Phone Number

Relationship to Participant

I have obtained consent from the participant to make this referral on their behalf

NDIS Details

NDIS Plan *

Plan Managed Self Managed

Support Coordinator Name *

Support Coordinator Phone Number

Support Coordinator Email Address *

Email Address for Invoicing *

NDIS Number *

Plan Start Date *

Plan Review Date *

Available Funding

File Upload - Please attach a copy of the current NDIS plan if possible

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Interests

Sessions I am interested in

1:1 SessionsGroup SessionsCommunity EventsShort Term Accomodation

Preferred Frequency:

WeeklyFortnightlyMonthlyJust when I need

*Please note we do not administer medication or undertake personal care.

What goals would you like us to help you achieve? *

My Support Worker Preference:

MaleFemaleBoth

Is there a support worker you would prefer to see via https://www.roostertours.com.au/meet-the-team

Is there anything else you would like us to know?

Fees & Charges

We charge NDIS rates (under CORE & Capacity Building Funding) in accordance with the NDIS Price Limits and Pricing Arrangements 2024-2025 (or as amended) which include (but not limited to):

$304.02 None-Face-to-Face Supports (initial registration charge of 4.5 hours) under 04_104_0125_6_1
$33.78None-Face-to-Face Supports(per service charge of0.5 hours foroutside sessioncommunications regarding progressand goal orientatedactivity planning) under 04_104_0125_6_1
$67.56 p/h CORE 1:1 Weekday Daytime - Assistance with social and community participation under 04_104_0125_6_1
$67.56 p/h CORE 1:1 Weekday Daytime - Assistance with social and community participation for Non Face-to-Face Support (Report Writing, Care Team Meeting Attendance, Capacity Building Research) under 04_104_0125_6_1 (quotes can be obtained for approval prior to the service)
$74.44 p/h CORE 1:1 Weekday Evening - Assistance with social and community participation under 04_103_0125_6_1
$95.07 p/h CORE 1:1 Saturday - Assistance with social and community participation under 04_105_0125_6_1
$122.59 p/h CORE 1:1 Sunday - Assistance with social and community participation under 04_106_0125_6_1
$150.10 p/h CORE 1:1 Public Holiday - Assistance with social and community participation under 04_102_0125_6_1
$67.56 p/h CAPACITY BUILDING - Assistance with daily living under 04_104_0125_6_1
$1.00 p/km for provider travel (to and from your home) and activity travel (to an from activities)
30 minutes of service for provider travel that involves more than 30 minutes travel
$33.78 per/use of Rooster Tours Activity Room [exclusive access in a rural setting {Yallourn North} including billiards (competition size table), darts, table tennis, tea/coffee/cooking station, golf, basket-ball, swimming (summer months only) under 04_104_0125_6_1
Short term accommodation, community events and group sessions incur a different rate which is disclosed and agreed with your prior consent via service agreement.
Support sessions are charged at not less then 2 hours in accordance with the Social, Community, Home Care and Disability Services Industry Award [MA000100]

Social Media Consent

I consent to Rooster Tours Pty Ltd taking, displaying and publishing digital photos of myself undertaking activities during sessions with my permission on their website, Facebook, Instagram and other social media platforms for marketing and promotional purposes.

Terms and Conditions

I adhere to the Code of Conduct, Terms & Conditions, Privacy Policy, transport & Personal Care Use Policy and Child Saftey Policy at Terms & Conditions (roostertours.com.au)

Where a Participant has a Short Notice Cancellation (or no show), we claim 100% of the agreed fee associated with the activity from the Participant’s NDIS plan for the arranged time of service including any out-of-pocket expenses incurred by us for the activity where agreed by the Participant.

A cancellation is a short notice cancellation if the Participant:

Does not show up for a scheduled support within a reasonable time, or is not present at the agreed place and within a reasonable time when the Provider is travelling to deliver the support; or
Has given less than seven (7) clear days’ notice for a support.

Medical Information

Diagnosed Disability and Medical Conditions *

Medication *

Feedback, Complaints & Disputes

If the participant wishes to give the provider feedback, the participant can contact Rooster Tours Pty Ltd via the contact details below . If the participant is not satisfied or does not want to talk to this person above, they can contact the NDIS Commission by calling 1800 035 544, visiting one of their offices in person, or ndiscommission.gov.au for further information.

Signature *

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Date