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Game On! Application Form
Game On! Application Form
Parent/Carer Details
First Name
Surname
Address
Suburb
State
Postcode
Email
Phone
Mobile
Date of Birth (DD/MM/YYYY)
Gender
Female
Male
Child Details
First Name
Surname
Date of Birth (DD/MM/YYYY)
Gender
Female
Male
Diagnosis (if any)
Siblings (Names and ages)
Aboriginal / Torres Strait Islander
No
Yes
Is your child involved in any other KidzWish programs?
Sports Academy Program
Speech Pathology
Occupational Therapy
Physiotherapy
Appeals Program
Any additional information you would like to provide
KidzWish aims to help children 0-18 who are sick, disadvantaged or have a disability. For statistical purposes, please tell us which category your child fits into.
My child is sick
My child is disadvantaged
My child has a disability
Availability
My child/children are available to attend
Term 1 (January-April)
Term 2 (April- June)
Term 3 (July-September)
Term 4 (October-December)
Emergency Contact Details
First Name
Surname
Phone
Mobile
Relationship
Getting to know your child
Tell us how your child communicates (e.g. verbally, sign language or communication device)
Tell us how your child moves (eg. Independently, needs some assistance)
If your child uses any movement or mobility aids, please provide details
Please describe your child’s interaction and play with other children
Please describe your child’s negotiation/problem solving skills
How does your child understand verbal directions/instructions and are there strategies we may use to assist their understanding?
Are there any activities your child tends to avoid?
Does your child require one on one support in social settings?
Does your child have any behavioural issues that we need to be aware of?
Yes
No
Please provide details and any strategies utilised to assist
Does your child have any sensory issues that we need to be aware of?
Yes
No
Please provide details and any strategies utilised to assist
Medical History
Does your child have any special dietary requirements?
Yes
No
Please provide details
Does your child have any allergies?
Yes
No
Please provide details
Has your child been immunised?
Yes
No
What date was your child immunised?
Any other additional medical details you would like to provide?
Does your child have any of the below
Hearing impairment
Hearing aids
Vision impairments
Additional Information
How did you hear about us?
Word of mouth
Email
TV
Print
Social Media
Internet Search
Family and Friends
Work and Organisation
Other
Other (please specify)
Parent/Guardian Consent
I certify that the information given on this form is to be best of my knowledge and a true account of my child’s current physical condition.
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Game On!
Game On! Application Form
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