Section 1: Client and Program Details
Are you a registered Novita client?
Yes
No
School Holiday Recreation Program
Please select...
Please select...
Primary School Age
High School Age
Mixed Age Program
Section 2: Child Details
Child First Name
Child Last Name
Child Preferred Name
Child Date of Birth
Gender
Male
Female
Other
Prefer not to say
Section 3: Child Address
Street Address
Suburb
State
Please select...
Please select...
NSW
VIC
QLD
WA
SA
TAS
ACT
NT
Postcode
Section 4: Additional Information
Does your child identify as Aboriginal or Torres Strait Islander?
Yes
No
Cultural Background
Main Language Spoken at Home
Section 5: Disability Specific Information
Primary Disability
Is your child under Guardianship of the Chief Executive?
Yes
No
Are there legal orders relating to this child?
Yes
No
Section 6: NDIS Details
NDIS Number
How is your NDIS plan managed?
Please select...
Please select...
Plan-Managed
Self-Managed
NDIA-Managed
Plan Manager Name
Section 7: Primary Carer
Primary Carer First Name
Primary Carer Last Name
Primary Carer Preferred Name
Primary Carer Date of Birth
Relationship to Child
Please select...
Please select...
Parent
Guardian
Grandparent
Sibling
Other
Primary Carer Mobile Phone
Primary Carer Email
Section 8: Health and Medical Information
Has your child received all age-appropriate immunisations?
Yes
No
If no, please provide details
I accept full responsibility if my child is not immunised
I accept full responsibility if my child is not immunised
Family Doctor Clinic
GP Name
GP Suburb
GP Phone Number
Section 9: Support Profile
Communication
Please describe your child's communication needs and preferences
Personal Care
Please describe any personal care requirements
Mobility
Please describe any mobility support needed
Behaviour (including triggers and de-escalation strategies)
Please describe any behavioral considerations and effective strategies
Section 10: Activities Participation
Activities
Please select activities your child may participate in:
Face Painting
Swimming
Animals
Gardening
Sensory
Excursions & Media
Please select approved options:
Local Walk
G Rated Movies
PG Rated Movies
Section 11: Declarations & Consent
Required Agreements
I agree to follow Novita's Terms & Conditions and Cancellation Policy
I certify that the information provided is correct and I will notify Novita of any changes
