NDIS Registration - Canberra Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Participant Name *Phone *Email *Date Of Birth *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodePlease select programs belowHoliday Program Week 1Flipout (Monday 30/09/2024)QPRC Aquatics (Tuesday 01/10/2024)Bowling/Timezone (Wednesday 02/10/2024)Treetops (Thursday 03/10/2024)Canberra Reptile Zoo (Friday 04/10/2024)Holiday Program Week 2PUBLIC HOLIDAY - NO ACTIVITY (Monday 07/10/2024)Hoyts - Beconnen (Tuesday 08/10/2024)Yarralumla Play Station (Wednesday 09/10/2024)iPlay (Thursday 10/10/2024)Power Kart Raceway (Friday 11/10/2024)Parents/Guardian Name (if applicable)NDIS Plan Start Date * NDIS Number *NDIS Plan End Date *Funding Management *Choose Funding managementNDIA ManagedSelf ManagedPlan ManagedFill in Your Plan Manager Details (if applicable)I give consent for photographs and/or videos to be published via various forms of media such as Social media, Website, Organisational or promotional material and Education and training purposes *Please SelectYesNoI Give Permission for Me/My Child to be Picked up And Dropped by CORE ASSIST DISABILITY SERVICES *Please SelectYesNoPlease List Any AllergiesPlease List Any Medications (name, date and time)Enter The Full Name Which Serves as The Electronic Signature for This DocumentSubmit