Email:

Date of Birth:

Age: *

As of the 5th February 2024

Postal Address: *

Caregiver Name:

Caregiver Contact Number:

Additional Caregiver:

please provide name and contact number and relationship to performer for any/all additional relevant caregivers

Goals for Performer:

Funding Type:

Please provide details if required for invoicing and documentation purposes

NDIS Number:

If applicable

NDIS Plan End Date

If applicable

Contact for Invoicing:

If NDIS funded and plan is third party/ plan managed, please provide the details of the agency including name of provider, email for invoicing purposes.

Diagnosis/es:

Please list if applicable

Current Medication:

Please list all below

Health/Medical Management

Please describe any medical or health management that may be required during classes (including if unlikely) e.g. seizure management, diabetes, falls risk, mental health concerns etc.

Allergies:

Please list ALL allergies, including minor or write NIL

Anaphylaxis Plan of Action Sent:

for clients with allergies/anaphylaxis.

Serious Injuries/Illnesses or Surgeries:

Please list any relevant and/or any in the past 5 years.

Motivators:

e.g. music artists/songs, activities, colours, props etc.

Physical Contraindications:

**any physical limitations the performer has**

Behaviours to Note:

please include any relevant behaviours, and information on how best to manage these in a group environment.

Communication:

e.g. key word sign, communication device, PECS etc.

Favourites!

Tell us your/the performers favourite themes, music, TV shows, movies or anything that motivates them!

Any Additional Information:

Media Consent:

Do you consent to the performer's image/video footage being used for online and social media purposes? **Please keep in mind that we are extremely conscious of only using media which supports our strong value of inclusion and we do not put names or any identifying information of performer's with any promotional material.**

Promotional Consent:

I agree to newsletters and promotional information from InMove to be emailed to my email.

Comments

Please note, a copy of the terms and conditions will be sent to sign following enrolment, fill in and return these as soon as possible. Please provide any further comments below

2024 Enrolment