Xperience - Registration Form

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Xperience Details:

Please select the Xperience you are registering for*

Participants details:

First Name

Last name

Street Address

Suburb

Postcode

Contact Number

Email for all correspondence

Would you/the participant like to be added to our Participation E-Newsletter?

Yes

Emergency Contacts details:

The Emergency contacts must be contactable during the Xperience.

Contact 1

Name

Relationship

Contact Number

Contact 2

Name

Relationship

Contact Number

Once you/the participant has completed and returned this registration form – this confirms your/the participants attendance, and you will receive a confirmation email.

Cancellations:

100% of costs will be charged if cancelled less than 7 business days from the 1st day of the confirmed Xperience. This includes the agreed NDIS supports, and user pay costs.

No Cost will be charged if cancelled more than 7 business days form the 1st day of the confirmed Xperience.

Please note: Days referred to in the notice period are normal working business days, Monday-Friday (8:00am – 4:00pm).

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Daily Contact Persons Details:

If you/the participant lives in supported accommodation and do not have regular contact with the person stated in “Emergency Contact” please include contact details of a person who supports you/the participant on a regular basis and can be contacted during the Xperience.

For example – If we need advice regarding medication, diet or support needs etc.

Name

Relationship

Contact Number

Further Participants details:

Date of Birth

YYYY

Gender

What pronouns do you/they go by

Disability Details

Fitness Level

General Health

Participant Requirements:

Dietary Needs:

Please list any dietary requirements. For example – gluten free, vegetarian or any religious related requirements etc.

Participants Medical History:

Do you/the participant experience or have experienced any of the following?

Diabetes

Seizures

Heart Problems

Epilepsy

Hay Fever

Hearing Loss

Sight Impairment

Allergies (medication, insects etc.)

Other

IF YES

If yes to any of the above, please give details:

Medication:

Please note ALL medication will be locked away during the Xperience. You/the participant will be allocated a medication file where you/they will put their blister (webster) pack and PRN (as and when needed) medications. This is then locked in our medication box until needed during the Xperience. This is to safeguard all participants attending. Medications can be refrigerated if required.

Do you/the participant have a Care Plan?

Yes

Don't Know

If yes, please send with this registration form.

Do you/the participant require ANY MEDICATION during the Xperience? - This includes daily medication and PRN medication such as paracetamol, eye drops, hay fever tablets, asthma inhalers etc.

Yes

If NO, please click "Next" at the bottom of this page.

Do you/the participant have any Schedule 8 Medications?

Yes

Don't Know

WADSA Staff are trained to support the administration of medication.

• A pharmacy generated medication signing sheet will be required for all medications (including routine prescription medication, PRN’s and over the counter medications such as Panadol, antihistamines, vitamins etc.) Signing sheets can be requested from the pharmacy when the blister (Webster) pack is created and will provide WADSA staff with necessary information to record the administration of medications.

• This signing sheet needs to be sent to WADSA prior to the Xperience.

• All tablet medications (including PRN’s) must be blister (Webster) packed.

• Blister (webster) pack should have your/the participants name/photograph on.

• All medications that cannot be stored in a blister (Webster) pack must have a pharmacy generated label attached and be accompanied by a pharmacy generated signing sheet.

• Labels on medication packaging must correspond with the pharmacy generated medication signing sheet.

• Signing sheets or labels on medication containers or packaging cannot be altered by WADSA staff, parents, or support workers

ANY MEDICATION PROVIDED THAT IS NOT DETAILED ON A MEDICATION SIGNING SHEET CANNOT BE GIVEN TO YOU/ THE PARTICIPANT.

Medication signing sheets and blister (Webster) packs can be easily obtained through your/the participants local pharmacist.

If you/the participant has any questions about our medication requirements, please contact the WADSA office on (08) 9471 1442.

Current Living Arrangements:
Current Living Arrangements:

Supported Accommodation

Independent

Family
Support Requirements:
Please detail any support needed for the following items. If nothing is written, we assume you/the participant requires no support.
GETTING UP IN THE MORNING - for example needs to be told its time to get up, help setting an alarm, help getting out of bed.
GOING TO BED – for example needs to be reminded it is time for bed, help getting into bed.
COMMUNICATION – for example are nonverbal, uses Auslan or Makaton, in certain situations cannot express themselves.
TOILETING - for example incontinence - uses adult incontinence products, sometimes has accidents during the night.
MOBILITY - for example needs help with stairs, uneven surface, uses a walking frame, uses a wheelchair, has poor coordination.
SHOWERING - for example needs help turning shower on and off, and regulating temperature, needs help to wash and dry.
EATING - for example needs help to cut food up, requires a spoon to eat, needs advice around portion size.
DRESSING - for example needs help to pick out appropriate clothes, needs help to get dressed and undressed.
ACTIVITIES ON THE XPERIENCE - for example will need encouragement to take part in activities, can be nervous around water.
SOCIALISING - for example can be shy in big groups, will need support when meeting and talking to new people for the first time.
TIME MANAGEMENT - for example needs help telling the time, will need a reminder to get ready in time for an activity or going out for dinner.
OTHER -

Helpful Information:

Alcohol
Are you/ the participant able to sleep on a top bunk?

Yes

No
Helpful Information
Do you/the participant have any unique behavioural characteristics or situational reactions that we should be made aware of in the interest of participant safety and/or satisfaction? For example – does not like loud noises.
Swimming Ability
Please clarify your/the participants swimming ability (Strong being competent swimmer able to swim a minimum of 50metres without stopping)

Strong

Medium

Poor

Non-swimmer
Helpful Information
Are there any recent or ongoing situations at home/work that may have some impact on you/the participant during the Xperience that we should be aware off?
Helpful Information
Is there anything else our staff can do to ensure you/the participant has the best possible time on the Xperience?

User Pay Costs
• User pay costs are a contribution towards accommodation, food and activities.

• All main meals, morning, afternoon tea and snacks will be provided.

• Any extra costs, such as entry fees for community activities, will be covered by WADSA.

• You/the participant will not need to bring any money to the Xperience.

• You/the participant are welcome to bring some money if you/they would like to buy a souvenir for example.

Code of Conduct:
A code of conduct is completed with you/the participants at the start of each Xperience. It is a great way to get everyone together so you/they can get to know each other, set the tone for the Xperience, set some goals, and have a chat.

You/the participants will help to decide how you/they should conduct themselves during the Xperience. It also gives everyone a chance to ask any questions. Examples of things covered in the COC include – phone use, showering, sleeping arrangements, tidying up after yourself etc.

If you/the participant would like more information about the Code of Conduct, please contact the WADSA office on (08) 9470 1442 or email [email protected].

WADSA Staff:
You/the participant will be designated a WADSA staff member for the duration on the Xperience. The staff member will provide the required support, assistance with medication (if required), support with activities and be available if you/the participant have any questions or are unsure of something.

Alcohol on the Xperience:
WADSA understands and recognises the importance of minimising harm from alcohol use. WADSA will ensure compliance with all relevant policy guidelines constructed by the Director of Liquor Licensing. Responsible consumption of alcohol may take place with food under WADSA staff supervision.

Please indicate if you/the participant attending Xperience can drink alcohol?
Alcohol

Yes

No

Other:
Are there any other details we need to be aware of?
Are there any other details we need to be aware of?

Declaration:

PARTICIPANT TO SIGN
Confirm registration completed
I confirm the registration has been completed with as much up to date information as possible.
I Confirm
Consent Medical Treatment
Where it is impractical to communicate with me, I authorise WADSA staff to consent to me receiving any necessary medical treatment or the use of an ambulance if required.
I Agree
Consent
I give my consent to be involved in the Xperience and the activities on the Xperience. I understand my participation is voluntary. I agree to accept the risk associated with participating in the Xperience and activities on the Xperience. I release WADSA from any claims of loss or damage that may arise from my participation.
I Consent
Dated

Name
Dated

Date

IF APPLICABLE, GUARDIAN/PARENT TO SIGN
Consent Medical Treatment
I confirm the registration has been completed with as much up to date information as possible.
I Confirm
Consent Medical Treatment
Where it is impractical to communicate with the participant/or myself, I authorise WADSA staff to consent to the participant receiving any necessary medical treatment or the use of an ambulance if required.
I Agree
Consent
I give my consent for the participant to be involved in the activities on the Xperience. I understand participation is voluntary. I agree to accept the risk associated with participating in the Xperience and activities on the Xperience. I release WADSA from any claims of loss or damage that may arise from the participant taking part.
I Consent
Dated

Name
Dated

Date

Photography:
PHOTOGRAPHS ARE OFTEN TAKEN AT XPERIENCES

If you/the participant do not wish to have your/their photograph taken during this Xperiences please leave this section blank.

PARTICIPANT TO SIGN
Consent
I consent to photographs of me, the participant, that are taken during the Xperiences can be used by WADSA for marketing or publicity purposes.
I Consent
Dated

Name
Dated

Date

IF APPLICABLE, GUARDIAN/PARENT TO SIGN
Consent
I consent to photographs of the participant, that are taken during the Xperiences, can be used by WADSA for marketing or publicity purposes.
I Consent
Dated

Name
Dated

Date

RELATIONSHIP TO PARTICIPANT

Relationship to Participant

IF YOU HAVE ANY CONCERNS OR QUESTIONS, PLEASE DO NOT HESITATE TO CONTACT THE WADSA OFFICE ON (08) 9470 1442 OR EMAIL [email protected].
REGISTRATION/S WILL NOT BE ACCEPTED WITHOUT PROOF OF PAYMENT (USER PAY AMOUNT)

• Registration Forms are to be completed in full for funding and insurance purposes. All information will be kept private and confidential.

• Payments must be made prior to an Xperience; failure to do so may result in the Xperience being cancelled unless prior arrangements have been made.

Payments accepted: Cash, Cheque, Direct Deposit Bankwest BSB: 306-052 A/C: 5529933 (Please put the date of Xperience and surname in the reference)

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Email
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Xperience – Registration Form

Step 1 of 12

Xperience Details:

Participants details:

Emergency Contacts details:

Contact 1

Contact 2

Daily Contact Persons Details:

Further Participants details:

Participant Requirements:

Participants Medical History:

Medication:

Current Living Arrangements:

Support Requirements:

Helpful Information:

User Pay Costs

Code of Conduct:

WADSA Staff:

Alcohol on the Xperience:

Other:

Declaration:

Photography: