Participant S Medical Condition(S)

Participant S Medical Condition(S)

/ PARTICIPANT SUPPORT PROFILE
Quality Document COM-F185

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Child's name(Participant)
Date of birth
Home address
Person completing form
Relationship to participant
Participant’s disability

PARTICIPANT’S MEDICAL CONDITION(S)

Is your child PEG fed?

Does your child have any of the following? A treatment Action Plan must be completed for each of the checkedconditions.

Allergy / Anaphylaxis / Epilepsy
Asthma / Diabetes / Others (Please specify in field below)

Note:1. Plans over 12 months old will not be accepted and enrolment will be revoked unless a new plan is provided prior to commencement of program

2.If your child requires medication whilst at the program, a Medication Administration Form will need to be completed each day your child attends the program.

Are there any diet restrictions? If yes, please identify

SUPPORT NEEDS

What level of support do you believe your child needs to participate in the outsideschool hours care program?

Constant one on one support to participate in activities

Minimal support by increased child/staff ratios to participate in activities (eg. 1 adult to 3 children)

Interacts in an appropriate manner with other children, using standard ISHC ratios (eg 1 adult to 15 children).

INDEPENDENCE SKILLS

Please tick if the skills that best describes your child.

Additional Details of Support Required

Physical Participation – Does your child
Open doors without assistance
Engage in tasks independently
Participate in craft activities
Climb unassisted
Participate in bat and ball games
Participate in team sports
Mobility – Does your child
Walk independently
Use a wheel chair
Require hoist for lifting
Manage stairs unaided
Self-Care – Does your child
Indicate their needs verbally
Require assistance with going to the toilet
Wear nappies /pull ups/pads
Require 2 staff to change nappies
Take themselves to the toilet
Wash hands independently
Require assistance dressing and undressing
Understand climate appropriate dress
Require supervision during meal times
Self-Care – Does your child have the ability to
Complete tasks for buttons and zips
Indicate their needs for food and drink
Feed themselves independently
Access food from bag
Drink from a cup
Communication – Does your child
Communicate verbally
Understand verbal instructions
Make eye contact
Understand nonverbal communication eg hand gestures
Does your child require communication aids?
Makaton Auslan CompicBoard Maker Other

BEHAVIOURAL AND SAFETY NEEDS

Please tick if the behaviours that best describes how your child responds in social situations

Additional Details of Support Required

How does your child respond in social situations?
Shy in new environments
Understands rules and boundaries
Engages in solitary play only
Engages in play with other children
Understands the concept of sharing
Requires close supervision in public area
Requires close supervision with access and exit doors
Has age appropriate road sense
Understands concept of stranger danger
Able to climb equipment
Able to cope with loud noise
Able to cope with new, large open spaces environments
How does the child demonstrate frustration or distress?
Does your child display any of the following behaviours?
Kicks
Hits
Spits
Bites
Swears / Self-harms
Has a tendency to run away
Sexualised behaviour
Hides
Other behaviour of concerns
Please provide details/triggers in relation to each of thebehaviours you have selected above
What strategies are successful in calming your child in these situations?
Please provide any additional information that may be beneficial to staff caring for your child

TERMS AND CONDITIONS

CONDUCTING THE PROGRAM
MOIRA will use reasonable endeavours to conduct the program. MOIRA may modify the program for operational reasons. If the program has insufficient participants, MOIRA may cancel the program and refund all fees paid.

OUTDOOR ACTIVITIES

When the program is outdoors, you must provide a hat and sunscreen which the participant must wear to participate. MOIRA will not supply sunscreen. You authorise MOIRA to apply sunscreen onto the participant.

INDOOR ACTIVITIES

You authorise MOIRA to allow the participant to watch videos or play games rated G or PG.

TRAVEL

You authorise MOIRA to transport the participant in program approvedvehicles and/or public transport.

COLLECTION AND VISITS

You must give written permission to authorise someone other than yourself to collect the participant or visit during the program. You agree that MOIRA ceases to supervise the participant once he or she is collected or signed out of the program.

OFFSITE LOCATIONS

For programs conducted offsite, MOIRA may ask a participant under 18 years of age to carry a device that reports his or her location in an emergency. If you decline the use of such devices, you must indemnify MOIRA for loss suffered by the participant which could have been avoided.

FEES

You must pay the program’s current fees and charges published by MOIRA. Additional fees may apply for some optional excursions.

REBATES

You are responsible for supplying all details needed to claim any child care benefits or tax rebates which may be available.

NO REFUNDS

MOIRA will not refund or waive fees if the participant is absent, sick or for any other cause.

CONTINUING WITH THE PROGRAM

The participant’s program enrolment is conditional on ongoing compliance with these terms and conditions.

THE PARTICIPANT

Must attend the program at the required times (unless a medical certificate is provided) Must not attend if the participant is unfit to participate (eg while suffering from contagious diseases or a medical condition), in which case you must promptly collect the participant.

Must abide by MOIRA’s policies and procedures

Must behave appropriately, must not bully others and must not place others at risk.

MOIRA MAY TERMINATE THE PARTICIPANT'S ENROLMENT IN THE PROGRAM

For a breach of the terms and conditions which cannot be resolved

For a breach of the terms and conditions notified to you which remains unresolved after 14 days

Where fees and charges are due and\or outstanding for more than 30 days.

WITHDRAWING FROM THE PROGRAM

Notice in writing is required to withdraw the participant from the program. A minimum notice of 2 clear business days is required. If notice is not given, this may incur a withdrawal fee (100% of fees to cover non-cancellable staff and resource commitments based on the participant’s enrolment in the program). In exceptional circumstance, MOIRA may allow the participant’s withdrawal on a shorter period or a lower fee than specified above.

MEDICAL TREATMENT

At all times you must supply MOIRA with full details of medical conditions which may affect the participant. You authorise MOIRA and staff in the event of the participant suffering from any injury, accident or illness, taking such action as it deems fit to obtain first aid, medical and/or hospital assistance and treatment. You undertake to indemnify MOIRA against all costs, actions and demands made against MOIRA and staff in respect or incidental to the costs, actions and demands.

LIMITATION OF LIABILITY

MOIRA’s liability for breach of these terms and conditions or for any other common law or statutory cause of action arising out of the operation of these terms and conditions in respect of any failure to provide the program in accordance with these terms and conditions is limited, to the extent permitted by law, to the fees paid by you to MOIRA. Where legislation implies in these terms and conditions any condition or warranty, and that legislation avoids or prohibits provisions in a contract excluding or modifying the application of, or exercise of, or liability under such condition or warranty, the condition or warranty shall be deemed to be included in these terms and conditions. However, the liability of MOIRA for any breach of such condition or warranty will be limited, at the option of MOIRA, to either (1) the supplying of the program again or (2) the payment of the cost of having the program supplied again.

RISKS AND INDEMNITY

MOIRA seeks to maintain a safe environment for all participants. However, accidents, theft of and damage to personal property, may occur. MOIRA excludes all liability for any direct or indirect loss, cost or expense suffered or incurred by you or the Participant and arising from accident, personal injury, illness or death (including mental illness arising from bullying) and property damage or destruction. You release MOIRA from claims arising in the above circumstances. You also unconditionally and continuously indemnify MOIRA against loss, cost or expense in defending a claim by you or the participant in the above circumstances in relation to a claim caused or contributed to by you or the participant in the above circumstances. Although MOIRA has various insurances in place, MOIRA cannot guarantee that the participant or the participant’s property will be covered by MOIRA’s insurance policies. As a result, MOIRA recommends that you consider obtaining your own insurance.

PRIVACY

Photography: Unless you specify “no” on the program enrolment form, you agree that the participant may be photographed for MOIRA newsletters, MOIRA’s internet site, and other publications.

COLLECTION NOTICE

The collection, storage, use and disclosure of this information is made in accordance with MOIRA’s Privacy Policy and the privacy principles contained in the Privacy Act 1988 (Cth) and the Health Records Act 2001 (Vic). In particular, MOIRA may disclose personal information to government agencies or funders to fulfil MOIRA’s funding agreements.

I agree that

I have provided sufficient information regarding my child’s health and additional needs for MOIRA to be able to make an assessment to determine the ability of the program to meet the needs of my child.

The information provided by me in this form is a true an accurate reflection of the needs of my child.

I understand that my applications may be refused in the event of the non-disclosure of relevant information.

I consent to non-identifying information being provided to Department of Health and Human Services (DHHS), Home and Community Care (HACC), Department of Training (DET).

I consent for MOIRA to obtain/give written and verbal information to/from service providers to assist with my child’s needs.

I have read and understood MOIRA’s Confidentiality & Privacy Policy (Quality Document, Policy 4) located on the MOIRA’s website (moira.org.au)

I have read MOIRAComplaints Guidelines (Quality Document U-D088) ) located on the MOIRA’s website (moira.org.au)

I have read and understood MOIRA’s terms and conditions.

Name
Signature
Date
1 / O:\PoliciesAndProcedures\Community Support\School Holiday Activity\COM-F185 Participant Support Profile.docx / Rev 02
Feb 17