Apply online


About you 
Given names
Preferred name
Date of birth
[Select date →]
Male  Female 
Height (cm)
Weight (kg)
Hair colour
Eye colour
NDIS Number
I have a
Mild Intellectual Disability  Moderate Intellectual Disability  Severe Intellectual Disability  Physical disability  Acquired Brain Injury  Visual Impairment  Hearing Impairment  Mental health condition  Dual diagnosis  Other 
My diagnosed condition(s)
2 - Where you live 
Street Address
Post code
Home telephone
Companion Card Number & Expiry date
I live in
Family home  Hostel  SRS  Supported accom  Respite house  Emergency/temporary accommodation  With flatmates  By myself  Other 
Parent/Guardian/Next of Kin (if still living at home or in supported accommodation) 
Parent/Guardian Name
Parent/Guardian Relationship to you
Parent/Guardian Address
Parent/Guardian Post code
Parent/Guardian Day Telephone
Parent/Guardian Evening Telephone
Parent/Guardian Mobile
Parent/Guardian email
Emergency Contact (24 hour contact details) This can be a case manager or a support worker if you prefer 
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Telephone
Is someone helping you fill out this form? 
The name of the person completing this form on your behalf
Relationship to you
Day Telephone
After Hours Telephone
Activities of interest 
Which Community Access activities and programs are you interested in today?
Sorrento Sundays  Peer to Pier events  Ladies who Lunch  Mate's Rates  A Company of Men  Daylesford Days  Animal Farm  Art and Culture  Out and About  Girl's Day Out  Hip Hop Madness  Lorne Burgers  Network  Run for your Life!  Plan Management Workshops  Holidays and Respite  Intern  Weekend Supports 
Based on participant feedback new programs and activities are developing all the time. So that you don't miss out, from time to time we may contact you via email or post to update you about the current programs we are running. Please let us know via the Contact Us page if you do not want this to occur.
General Information 
Please tick the items that apply to you
Do you smoke?  Do you drink alcohol?  Are you capable of independently and safely preparing hot drinks?  Do you want staff to look after your spending money?  Are you capable of independently transferring in and out of a wheelchair?  Do you require assistance getting in and out of a vehicle?  Do you require assistance using the toilet or bathroom?  Do you experience difficulties interacting with other people?  Do you have behaviours of concern?  Do you currently have a behaviour management plan?  Do you require one-to-one support?  Have you ever absconded during an activity?  Would you like staff to supervise or prompt you to take medication during your time with us? 
Do you have allergies or dietary requirements?
In the event of an allergic reaction, will you require medical treatment?
Do you experience seizures?
Yes  No 
Type of seizures
Possible triggers
Medical response
Please provide further information about your individual safety management plan if relevant
Methods of recording
I/we have read and understood the Community Access terms and conditions and the rights and responsibilities which outline the mutual obligations and expectations which form the terms of contract.

I/we agree with the stated terms and conditions and understand that the submission of this online form creates a service agreement with Community Access. All services provided by Community Access including attendance at their events, programs, supports and activities are considered reasonable and necessary, and will assist the participant named on this application to achieve the goals that correspond to the services provided and as outlined in their NDIS plan.

I declare that the information provided on this form is true and accurate to the best of my understanding.

Note: The submission of your name and date on this form is considered an electronic signature. Upon request a hardcopy of this form can be sent to you via post.

Terms and conditions.pdf

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