Youth School Holiday Program

The Summit Registration Form

Details

Join us for a fun day of adventure, nature, making friends and food!

Aim

This program is an amazing space that:

provide new opportunities for disadvantaged and vulnerable youth in a safe and inclusive environment
create meaningful experiences and friendships
offer support and respite for participants and their care givers
build skills and community connection while having fun

Inclusions

Laser skirmish
Flying fox
Giant swing
Obstacle course
Nature walks, and so much more!
Snacks, lunch, drinks
Travel (if requested) - Pick-up/drop-off from home
Mentoring & support from a team of experienced Support Workers

Eligibility

To participate you must meet the following age and participant criteria:

I am between 12 and 24 years of age

I am a participant of NDIS

I receive support from DFFH and/or Child Protection Services

I receive support from Orange Door

I receive support from Quantum

Other

If Other, please describe:

Location

The Summit Adventure Park, 21 Cemetery Road Trafalgar East

Date and Time

Thursday 26 September 2024 from 9am to 4pm

Accessibility

This is a wheelchair friendly event.

I have a wheelchair

I have a walking aid

Please describe:

Costs

The total cost of the program with all inclusions (including travel) is $851.11*

*Please note the above support items are calculated in accordance with the National Disability Insurance Scheme Pricing Arrangements and Price Limits 2023-24. These prices may change depending on any amendments made to the Pricing Arrangements by the NDIS including indexing for the upcoming financial year.

Participant Registration Details

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address

Address *

Cultural Background, Beliefs & Preferences

Is the Participant Aboriginal and Torres Straight Islander?

YesNo

Does the Participant speak English?

YesNo

If no, please describe:

Invoicing

Agency Name (Note this is not required if you are already a participant registered with Rooster Tours)

Agency Contact (Note this is not required if you are already a participant registered with Rooster Tours)

Invoicing Email Address (Note this is not required if you are already a participant registered with Rooster Tours)

NDIS Reference Number (Note this is not required if you are already a participant registered with Rooster Tours)

Transport

I require transport to and from home

I do not required transport and will meet everyone at the venue

Dietary Requirements

My diet requests are:

Allergies

I have allergies:

YesNo

If yes, please describe your allergies including required treatment management plan:

Medical Information

I have a diagnosed disability:

YesNo

If yes, please describe:

I require behaviour management:

YesNo

If yes, please describe & include strategies required to assist:

When I am having an urgent health situation the steps my support worker needs to follow are:

Is there anything else we need to know to support you:

GP Name:

GP Phone Number:

Medication

I take medication:

YesNo

If yes, please describe your medication:

I will be bringing medication to this event:

YesNo

Please describe the medication you will be bringing:

I require Rooster Tours to administer my medication during this event and give them my consent:

YesNo

If yes, please provide instructions including the medication in a sealed and clearly label bag with your first and last name:

Ambulance Cover

I have ambulance cover:

YesNo

I have a health care card:

YesNo

If yes, please provide CRN:

I have private health insurance

YesNo

If yes, please provide name of fund and policy number:

Emergency Contact

Emergency Contact 1:

First Name *

Last Name *

Phone Number *

Relationship 1

Emergency Contact 2:

First Name *

Last Name *

Phone Number *

Relationship 2

Court Order

This information is collected to help protect our team, the community and yourself. We guarantee the confidentiality of the details you provide us. Are there any current court orders in place?

YesNo

If yes, please provide details:

Upload Court Order

Browse

Cancellation Policy

By ticking this box, I understand that supports cancelled with less than 7 days notice (excluding medical emergency, family emergency, environmental emergency or Covid related circumstances) will be charged at 100% of the program cost.

*

By ticking this box, I understand that supports cancelled with less than 2 weeks notice may be charged a cancellation fee to cover any out-of-pocket costs incurred by Rooster Tours Pty Ltd due to the short notice.

*

Social Media

The team at Rooster Tours will be taking digital photographs during the event for publishing on their website, Facebook, Instagram and other relevant social media platforms for marketing and promotional purposes.

Please tick the box if you do not consent to us taking and publishing photographs containing you in them.

Privacy Policy

By ticking this box, I consent to my private information being held, protected and shared by Rooster Tours Pty Ltd in accordance with the privacy policy.

A copy of our 'Privacy Policy' is available on request via info@roostertours.com.au or online via Terms & Conditions (roostertours.com.au)

*

Code of Conduct

By ticking this box, I agree and adhere to the Code of Conduct of Rooster Tours Pty Ltd.

This includes no vaping, cigarettes, illicit drugs or alcohol or they will be confiscated.

A copy of our 'Code of Conduct' is available upon request via info@roostertours.com.au or online via Terms & Conditions (roostertours.com.au)

*

Electronic Devices & Personal Items

By ticking this box, I agree that I am fully responsible for my phone, electronic devices and any valuables I have chosen to bring to this event.

*

Feedback, Complaints and Disputes

If you wish to give us feedback or raise a complaint, please contact Rooster Tours on 0414 377 347 or info@roostertours.com.au

If you are not satisfied with our service, or do not want to talk to this person above, please contact the NDIS Commission on 1800 035 544, visiting one of their offices in person, or ndiscommission.gov.au for further information or raise a complaint the Victorian Ombudsmon on 1800 806 314 or ombudsman.vic.gov.au

Contacts

Natalie O'Shea

Director | Coordinator, Social Support Services

Rooster Tours Pty Ltd

0414 377 347 | info@roostertours.com.au | www.roostertours.com.au/contact

Participant or Representative Signature

Signature *

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Date