Social Groups Booking Form

Please complete this form to register your interest in our Beyond Speech School Holidays Social Groups. Once this form is received, our admin team will issue you an invoice. Your place in the group will be secured once payment is received. Please feel free to contact admin if you are unsure about any aspect of this form admin@beyondspeech.com.au or 0417 035 016.

Your Full Name *

Your Child's Full Name *

Child's Date of Birth *

Child's Age *

Child's Gender *

Child's Grade/Year level *

Contact Number *

Address *

Town *

State *

Postcode *

Email *

Has your child accessed services with Beyond Speech over the past 12 months? *

YesNo

Is your child currently on the Beyond Speech waiting list? *

YesNo

Which Social Group would you like your child/teen to attend: *

Sensory Superstars (Ages 4-7): Tuesday, June 30th to Thursday, July 2nd from 9:00am - 10:30amPop Culture Club (Grades 1 to 6): Tuesday, June 30th to Thursday, July 2nd from 2:00pm - 3:30pmTeens Gaming and Cafe (Years 7 to 12): Tuesday, June 30th to Thursday, July 2nd from 12:00pm - 2:00pmMinecraft Adventure Group (Grades 1 to 6): Tuesday, June 30th to Thursday, July 2nd from 10:30am - 12:00pm

Please describe any challenges your child experiences that may impact their participation in the group (eg. emotional regulation difficulties, fine motor difficulties, hitting out when angry etc) *

What are your child's current goals and what do you hope to get out of attending the group? *

What works best to support your child if they become distressed or dysregulated? (eg. going to a quiet space for a break, taking a short walk, using sensory toys, having a drink of water) *

Funding

How will you fund the group program (total of $525 for the Primary School Groups or $739 for the Teen Group for 3 days): *

Private Paying with NDIS funds (Self-Managed)with NDIS funds (Plan-Managed)Other (Please specify below)

Other Funding

Plan Manager email:

You acknowledge that: *

The Teens Gaming and Cafe group will involve walking to a local cafe. The Teens Gaming and Cafe group members will need to bring $20 to spend each day.We encourage you to bring a support worker along to the group sessions if this may help you to stay safe, manage interactions and engage more effectively.Registration is subject to approval by clinical staff at Beyond Speech.Refunds are not available for cancellations or non-attendance to any session.Beyond Speech is not liable for any declined reimbursements from NDIS.

We will be in contact to supply you with an invoice. Your booking will be confirmed once payment has been received.

For any questions, please feel free to contact us on 0417 035 016 or at admin@beyondspeech.com.au

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