Xperience - Expression Of Interest

Have you attended a Play On/WADSA event before?*

I have attended a Play On / WADSA event before

This is my first time

Please check the box below if you are applying on behalf of the person participating in the experience.*

A family member or guardian

An agency or plan manager

Other

Participant details

First Name*

Last name*

Phone*

Email for all correspondence*

Street Address*

Suburb*

Postcode*

Date of Birth

Day

Month

Year

Please provide details of your disability.

Please select the required support ratio.

1:1

1:2

1:3

1:4

Funding

Do you receive NDIS funding?

Yes

No

First Name*

Last name*

Phone*

Email*

Date of your next plan review

Day

Month

Year

Name*

Phone*

Email*

Choose an Xperience

How many Xperiences will you have funding for in your current Plan?

Not Sure

Please list in order of preference, the Xperience or Xperiences you would like to attend.

Goals

Please select the goals you hope to achieve by attending a Play On Xperience.

Improving your health and wellbeing

Increasing your independence in daily living

Building or maintaining relationships

Social and Community participation

Learning new skills

Other

How did you hear about Play On Xperiences?

CAPTCHA

Xperience – Expression Of Interest

Participant details

Funding

Choose an Xperience

Goals