Enquiry Form

Do you have a primary diagnosis of an Intellectual Disability? Do you have a primary diagnosis of an Intellectual Disability? Yes No

Do you have NDIS funding? Do you have NDIS funding? Yes No

Are you aged between 17 and 65 years? Are you aged between 17 and 65 years? Yes No

NDIS reference number

How do you manage your NDIS plan? How do you manage your NDIS plan? NDIA Managed Plan Managed Self-Managed

Participant's name

Date of birth

Address

Phone (home)

Phone (mobile)

Select your programs of interest Select your programs of interest Lifestyle, leisure and learning Skills for life My future 1:1 support – assistance with daily living 1:1 support – assistance with social, economic & community participation ROPE bus transport (pick-up and drop off from allocated points) ROPE annual recreational camp Friday Night Dinner Dates (monthly)

Parent/advocate's name

Address

Phone (home)

Phone (mobile)

Email address