Registration Questionnaire

Camp Start Date *

Child's Information

Child's First Name *

Child's Last Name *

Child's Date of birth *

Child's Gender *

Male
Female
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Child's Address *

What ratio of support will the child require? *

1:3

1:2

1:1

Child's NDIS Number *

How is the child's NDIS plan managed? *

Self Managed

Plan Managed

Agency Managed

Parent or Guardian Information

Full Name *

Email *

Phone *

Relationship to the Child *

Emergency Contact Information

Emergency Contact Full Name *

Emergency Contact Phone Number *

Support Coordinator Information (if applicable)

Full Name of Support Coordinator

Support Coordinator Phone Number

Support Coordinator Email

Do you authorise Nature Moves to contact your support coordinator?

Yes

No

Plan Manager Information (if applicable)

Plan Manager Full Name (or company name)

Plan Manager Phone Number

Plan Manager Email

Do you authorise Nature Moves to contact your Plan Manager?

Yes

No

Additional Child Information

What language does the child speak at home? *

Does the child require a communication device? *

No

Yes

What is the child's diagnosis (please include all if there are multiple) *

Does the child take any medications? *

Yes

No

Will the child take medication while at camp? *

Yes

No

Does the child have any allergies? Including food, medication, etc *

Yes

No

If the child has any allergies, please list them here *

Does the child have any complex behaviours or medical conditions? *

No

Yes

Does the child have any restrictive practices in place? *

No

Yes

Has the child spent nights away from family before? *

Yes

No

Do you have any concerns about the child sleeping in a tent? *

No

Yes

Does the child have any difficulties with sleep? *

No

Yes

Do you have any concerns about sensory sensitivity using a sleeping bag? *

No

Yes

Is the child swimming proficient? *

Yes

No

Does the child have any physical disabilities? *

No

Yes

Does the child need help with self-care? *

No

Yes

Does the child have any food preferences or restrictions? *

No

Yes

What are the child's 3 favourite foods / meals?

Do you consent for Nature Moves to use photos or videos of the child for social media, website or any other marketing platforms? *

Yes

No

Signature of child's parent or guardian completing this form *

Clear

I agree to terms & conditions provided by Nature Moves Pty Ltd. By providing your phone number, you agree to receive text messages from Nature Moves.