Registration Form Community Access

VIDA CARE REGISTRATION FORM FOR COMMUNITY ACCESS
ABN: 82 636 352 782 TEL: 1300 MY VIDA
I:
Name:*
Wish to register for community access with Vida Care and claim for my supports from my NDIS packages as outlined within the conditions in my Service Agreement.
NDIS #:*
D.O.B:*
Address:*
Fund Type*
NDIA Managed PlanPlan Managed:Self Managed
Disability / Medical Conditions :
1.*
2.
3.
Important Information:
Allergies / Intolerances:
If required, the Management Plans below are to be provided to Vida Care:*
EpilepsyAsthmaSubcutaneous InjectionsTracheostomy ManagementEnteral Feeding ManagementComplex Bowel CareVentilator Management
Diabetes*
Complex Wound Management*
Urinary Management*
Communication:
Can the Participant communicate their needs?*
YesNoVery difficult to understand
Health Details:
Medicare Number:
Expiry Date:
MonthDayYear
Date
Reference Number:
Private Health Care
Mebership Number:
Provider:
Private Health Care Provider:
Reference Number:
Doctor Name:
Doctor Address:
Doctor Phone Number:
Date of last tetanus injection:
MonthDayYear
Date
Does the Participant require assistance with medication?*
YesNo
If yes, you will need to have your doctor complete a "Medication Purpose Form" which we will provide.
Mobility:
Does the Participant have any mobility issues?*
YesNo
Personal Care:
Does the Participant require assistance with toileting?*
YesNo
If yes, please provide details:
Diet Restrictions:
Does the Participant have any dietary restrictions?*
YesNo
If yes, please provide details:
Behavioural Concerns:
Is the Participant naturally quiet and reserved or is he/she more lively and outgoing?*
QuietActiveVery Active
Does the Participant have a tendency to abscond?*
YesNo
Does the Participant have any fears we should be aware of?*
YesNo
If yes, please provide details:
Does the Participant have any behaviours we need to be aware of?*
YesNo
If yes, please describe the behaviour and any strategies to deal with the behaviours:
What are some of the Participants likes / dislikes:
Likes
Dislikes
Does the Participant have any criminal history we need to be aware of? If so, meetings will be scheduled to formulate safety and risk assessments*
YesNo
I understand that:
• These records are owned by Vida Care
• Information within these records will be shared with other staff within Vida Care on and only when staff require the information to carry out duties
• I can ask to see records and receive a copy of records
• Records are archived for a set period of time according to the Policies and Procedures of Vida Care
• I understand that all information obtained will be kept confidential To the best of my knowledge, the information provided in this form is true and correct.
Name of Participant:*
Signature:*
Clear
Date:*
MonthDayYear
Date
Name of Participant Representative:*
MEDIA AUTHORIZATION FORM
I:
Participants Full Name (Please Print):*
Agree and acknowledge that I am the parent/guardian/carer of the Participant named above and that by signing this form I:
• Consent to video footage/photos/other images/work of the mention Participant being collected, stored and used by Vida Care during the course of services delivered to my family and the Participant for a variety of public relations, communications and promotional activities, including but not limited to publications, promotional material, websites and advertisements, for an undefined period of time.
• Understand that any video footage/photos/other images/ work may be shown in a public environment.
• Agree that the named Participant’s participation in promotional activities and/or publications may be edited at the sole discretion of Vida Care.
• Release Vida Care from any claim by me or anyone on my behalf and arising out of the named Participant’s appearance in promotional activities and/or publications.
• Acknowledge that there is to be no payment or further consideration paid for the named Participant’s video footage/photos/other images/work.
• Understand that Vida Care will manage all personal information in accordance with legislative obligations for privacy and confidentiality.
• Consent for the video footage/photos/other images/work to be used for an undefined period of time unless notification is given in writing to the Management Team at Vida Care.
Signature:*
Clear
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VIDA CARE REGISTRATION FORM FOR COMMUNITY ACCESS

I:

Disability / Medical Conditions :

Allergies / Intolerances:

Communication:

Health Details:

Private Health Care

Provider:

Reference Number:

Mobility:

Personal Care:

Diet Restrictions:

Behavioural Concerns:

What are some of the Participants likes / dislikes:

Likes

Dislikes

I understand that:

MEDIA AUTHORIZATION FORM

I: