WP E-Signature by Approve Me - Sign Documents Using WordPress -

New Client Information Contract

General Information

Child's Name: Date of Birth: Age: Gender:

Carer 1:

Relationship to Child:
Date of Birth:
Occupation:
Mobile:
Email Address:

Carer 2:

Relationship to Child:
Date of Birth:
Occupation:
Mobile:
Email Address:

Home Address: Suburb: State: Postcode:

Name and age of other children/siblings at home:

School/Preschool/Childcare details: Grade: Teacher:

Paediatrician: General Practitioner: Clinic:

Medicare Card Number: Parent Reference Number: Child's Reference Number: Expiry:

Diagnosis

Diagnosis: Details (if any): Date of Diagnosis: By Whom:

Assessment

Previous Assessments Completed: Summary/Details of Assessments (if completed):

National Disability Insurance Scheme Funding

I will access services through the National Disability Insurance Scheme (NDIS):

If yes, my NDIS Plan is:

Plan Manager Details:

Name:
Contact Number:
Contact Email:
Invoice Email:

Medicare

I will access services through Medicare:

I have the following Medicare Plans and was referred by at

Private Funding

I will access services through private funding: . If yes, my private health insurance fund is:

Emergency Contact Declaration

Emergency Medical Conditions/Diagnosis:

Allergies:

Physical Limitations or Injuries:

In case of emergency please contact:

Emergency Contact Name:
Relationship to Child:
Phone Number:

If we can not be contact in an emergency and it is deemed necessary I give permission for Family Time Australia to call an ambulance.

Authority to Release Information:

I/We herby give my/our permission for Family Time Australia to access personal details, relevant to your child/ren.

Including any medical information and documentation on file that I/We have supplied or has been sent on behalf of us and/or said child/ren, including but not limited to Referrals, Letters, Assessments, Diagnosis, Treatment Notes and Recommendations and Funding Arrangements.

I understand that the information will be treated confidentially and if it is published for statistical purposes in any way, it will not identify the child/ren or any other family member of our/my family. I understand that I may withdraw at any time in the future by giving written notice.

Photo Consent

I agree that my child may be filmed or photographed during their class program for the following:

Programming and planning
Educational purposes
advertising or public notices including Television, Website, Facebook, Flyers or Newspaper.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Signed by Family Time Australia
Signed On: August 27, 2020

Timestamp

Audit

July 4, 2020 12:28 pm ACDT

New Client Information Contract Uploaded by Family Time Australia - enrolments@familytimeaustralia.com IP 14.2.74.162