EVENTS AND PROGRAMS FORM

I AM INTERESTED TO ATTEND... *

CHRISTMAS IN JULY MORNING TEA 23 JULY 2026PAINT & POT WORKSHOP1 AUGUST 2026PAINT & POT WORKSHOP2 AUGUST 2026HALLOWEEN MORNING TEA 22 OCTOBER

Participant Details

First Name *

Last Name *

Phone Number *

Email Address

Emergency contact

Full Name *

Phone Number *

NDIS Details (if applicable)

Plan

Plan Managed Self Managed Agency Managed

Plan Manager Name (If Applicable)

Plan Manager Agency (If Applicable)

NDIS Number

Plan Start Date

Plan End/Review Date

Goal term

Participant Goals As stated in the NDIS plan

Support needs

Type of Support required

Additional Information on Support Needs

Dietary Requirements (if any) *

Referrer Details (Person Making the Referral if applicable)

First Name

Last Name

Agency

Role

Email Address

Phone Number

I have obtained consent from the participant to make this referral and provide District 360 with the participant's personal and medical details.

Thank you for expressing interest in our program. A member of our team will be in touch shortly to offer more details and assist with the necessary documentation.

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