Intake Form

Complete Our Online Intake Form

For your convenience, you can submit your child’s details directly through our secure e-form. This information helps Dominic understand your child’s interests and communication style so we can find the perfect session match.

1. Participant Details

Full Name

Date of Birth NDIS Number NDIS Plan Management Company NDIS Plan Expiry

2. Parent/Guardian Contact Information

Primary Contact Name Phone Number Email Address Relationship to participant

3. Secondary Parent/ Guardian or Emergency Contact

Secondary Contact Name Phone Number Email Address Relationship to participant

4. Medical Information

Does your child have any diagnosed medical conditions (e.g. asthma, epilepsy)? YesNo If yes, please list diagnosed condtions

5. Behaviour & Support Needs

Key triggers or stressors Preferred calming strategies or tools Can your child participate safely in a small group environment? YesNo Is your child at risk of attempting to abscond from the session/venue? YesNo

6. Authorisations

I give permission for photos to be taken of my child for participant’s parents updates after the session Yes I confirm that all information provided is accurate and agree to notify Play Panda Social Club if any details change. Yes

7. Signature

Parent/Guardian name Signature

Date

Download & Print Enrolment Form

If you prefer to complete your paperwork manually, you can download the PDF version of our enrolment form here. Once finished, please email the completed copy to PlayPandaSocialClub@gmail.com to begin the intake process.