Up!Club Participant Form

Please populate the form below with your information. Down Syndrome NSW use this information to create your Down Syndrome NSW participant profile, and to provide streamlined communications based on your profile and preferences. Please scroll down the form and ensure you have all your information and documentation before starting.

The Down Syndrome NSW Privacy Policy can be found at www.downsyndrome.org.au/nsw/upclub.

Participant First Name *

Participant Last Name *

Participant preferred name:

Mobile number: *

Email Address *

Date of Birth: *

Gender

FemaleMaleOtherPrefer not to say

Do you identify as Aboriginal or Torres Strait islander?

YesNoPrefer not to say

To what culture do you identify most closely?

Primary language spoken at home?

Is the participant proficient in English for the purpose of attending workshops and activities held in English?

YesNo

Is an interpreter required?

YesNo

Do you live at home with family?

YesNo

If no please specify arrangements, otherwise type N/A

Address *

Street address *

City *

State *

Postcode *

What type of area do you live in? *

MetropolitanRegionalRemote

Do you attend school of tertiary education?

Yes, primary schoolYes, secondary schoolYes, tertiary educationNo

Do you go to work?

YesNo

If yes, what is your job title?

If yes, please provide the name of the organisation where you work:

Do you have a Companion card?

YesNo

Are you a NDIS participant? *

NoYes- NDIA ManagedYes- Plan ManagedYes- Self Managed

NDIS number: *

NDIS Plan Start Date *

NDIS Plan End Date *

Please list your NDIS goals as per your current NDIS plan, or type N/A: *

Please upload a copy of your NDIS goals (if applicable)

Browse

Parent / Carer Contact 1 Information (Primary contact during activities)

Parent/Carer name: *

Parent/Carer mobile number: *

Parent/Carer email address: *

Relationship to participant: *

Parent / Carer - Contact 2 Information

Parent/Carer 2 name:

Parent/Carer 2 mobile number:

Parent/Carer 2 email address:

Parent/Carer 2 relationship to participant:

Contacts to receive Up!Club information

Could you please list all parties email addresses that will need to receive Up!Club information and/or programs - so that all of your support people are well informed.

Medical Information

Please note Down Syndrome NSW use this information for risk identification and mitigation purposes. We do not administer or provide reminders for medication during our activities.

Do you have Down syndrome? *

YesNo

Do you have a medical condition / disability other than Down Syndrome? *

YesNo

If yes please specify

Do you have food allergies or dietary requirements? *

YesNo

If yes please list

Do you take any medication? *

YesNo

If yes please specify name, dosage and frequency.

Please note Down Syndrome staff and volunteers do NOT provide any medication assistance.

Communication and Behaviour Support

We use this information when preparing to facilitate Up!Club events.

How do you communicate? *

Verbal - EnglishVerbal - otherNon-verbalOther

Please provide details of your communication if selected other.

Do you have a behaviour support plan? *

YesNo

Please upload your behaviour support plan (if applicable)

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All about me!!

My name: *

My age: *

Please upload a photo of you! *

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What people appreciate about me...

What is important to me...

How to best support me...

Questionnaire

Please list the names of other services and or supports that you also receive - if you would like to share.

If yes, please give name.

What activities do you enjoy eg. sport, dancing, singing? *

Other hobbies / interests? *

What do you hope to achieve from participating in Up!Club activities? *

Do you have any concerns regarding Up!Club? *

Declarations

I have communicated all relevant information to DSNSW to help make Up!Club a safe and fun environment for me. *

YesNo

I give permission for any photos/videos taken during up club activities to be used for DSNSW communication and /or marketing purposes. *

YesNo

The information provided above is true to the best of my knowledge. I understand that providing false information may lead to the termination of Down Syndrome NSW membership *

Name of signatory (If participant is under 18 years of age, this form must be signed by a parent or carer) *

Signature (typed signature is accepted) *

Draw signature|Type signatureClear

Date: