Web

Workshop enrolment
and application for service agreement
(for NDIS participants who are Plan or Agency-Managed)

In order to use NDIS Funding to attend an Autism Queensland workshop we require you to complete the following form. Upon receipt of this information we will draw up a Service Agreement.
NB If funding is self-managed you do not need to complete this form. Please return to the workshop booking page and complete as required, including the name of the participant in the notes.)

Name of the workshop/s you wish to attend:* (required)
	(Please provide names of all workshops you will be attending)

Workshop date/s:* (required)
	(Please include all dates of workshops you will be attending)

Attendee Name:* (required)
	(Please provide full name.)

Attendee Email:*

Would you like to receive updates about future workshops?

Yes

SECTION 1: NDIS PARTICIPANT DETAILS (person receiving NDIS funding)

Name (if different to attendee)
	(Please provide full name.)

NDIS Number:*

Date of Birth:*

plea

PLEASE COMPLETE IF THE PARTICIPANT IS AGED UNDER 18:

Parent/carer* name (If different to workshop attendee)
	*(Automatically considered to be a child’s formal guardians; referred to as participant representative throughout the remainder of this document.)

Address:
	(Please provide your full address including suburb and postcode.)

Contact number:

Email :

PLEASE COMPLETE IF THE PARTICIPANT IS AGED OVER 18:

Does the participant have a formal guardian and/or an official NDIS nominee*?

Yes (provide details below if different to attendee)

(A nominee is a person who is appointed in writing, at the request of a participant, or on the initiative of the NDIA, to act on behalf of, or make decisions on behalf of a participant for the purposes of the NDIS Act. If a guardianship arrangement is in place the presumption is that the guardian will be appointed the nominee (NDIS website).)

Name:

Address:

Contact Number:

Email:

Does the participant have a informal decision maker*?

Yes (provide details below if different from attendee)

(An informal decision-maker is a family member, carer or other significant person who can assist the participant by making a decision where there is no conflict about it and where it does not jeopardise the well-being of the participant.)

Name:

Address:

Contact Number:

Email:

* (To be referred to as the participant’s representative for the remainder of the document.)

SECTION 2: PAYMENT OF FEES

(Select one option below: ie Plan-managed, agency-managed)

Plan-managed

The participant/participant’s representative has chosen to have the NDIS funds managed by a Plan Manager?

Yes - please provide details below; invoice will be sent to plan manager.

Plan Manager Name:

Company:

Address:

Email:

Agency-managed

The participant/participant’s representative has chosen to have the NDIS funds managed by the NDIA.

Yes - invoice will be sent directly to NDIA.

Personal and sensitive information collected on this form will be retained and used for the purpose of providing you with Autism Queensland Limited’s services and providing information about these services. It may also be used for other purposes such as providing you with information about other services and events, to meet our requirements for government funding in providing services, to monitor and evaluate existing services and plan for future services or for research purposes. Without this information Autism Queensland may be unable to provide you with its service. The information collected on this form will only be used by Autism Queensland and will not be disclosed to any other person or organisation unless we have your consent or we are permitted by law. If you wish to access or seek correction of your personal information or make a complaint about our handling of your personal information please see Autism Queensland’s Privacy Policy or phone (07) 3273 0000.

Autism Queensland
P. 07 3273 0000
E. css@autismqld.com.au