Participant Details

First name

Last name

Residential Address

Date of Birth

Participant Contact Details

Home Phone

Mobile Number

Email Address

Program Details

Which programs are you registering for?

COOK+CONNECT @ CENTRE

COOK+CONNECT @ HOME

COOK+CONNECT @ WORK

COOK+CONNECT @ COMMUNITY

What are your goals in relation to the program?

What days of the week are you available to participate in the program?

Nominated Parent/Guardian Details

First Name

Last Name

Relationship

Home Phone Number

Mobile Number

Email Address

Can this person be contacted during program hours?

Yes

No

Participants Background Information

Please select all that applies to the Participant

Is the Participant of Aboriginal or Torres Strait Islander Origin?

Yes, Aboriginal

Yes, Torres Strait Islander

No

Are there any behaviours that may be triggered when working in a group?

Are there any behaviours that may be triggered when working in a kitchen?

Do you have any food allergies or intolerances?

Support Information

This information is confidential and will assist us in helping you to achieve your personal goals.

BMFS PROVIDES TWO SUPPORT PEOPLE, ONE OF WHOM IS THE FACILITATOR.

Will you need to arrange additional one-on-one support?

Yes

No

If yes, please provide support worker name and contact details.

Are there any specific cultural, values and or beliefs that we need to take into consideration in the Program?

Yes

No

If yes, please provide details.

Does the Participant have a Behavioural Support Plan?

Yes

No

If yes, please provide details

Please note that all participant’s personal information is strictly confidential and all personal information is stored in a lock filing cabinet and on a password encrypted database.

How will the Participant be travelling to and from the Program?

If the Participant is being dropped off and picked up, can they wait unsupported for transport after the Program?

Participant Funding Details

NDIS Number (If Applicable)

Name of Support Coordinator (if applicable)

Support Coordinator's Phone Number

Support Coordinator's Email Address

What funding is available in the Participant's Plan?

Core Supports

Social Participation

Improved Daily Living

Other

How is it managed?

NDIA Managed

Self-managed

Email address for invoices:

Plan Managed

Name:

Email address for invoices:

Specific Program Changes Required

Please enter the specific changes required when delivering the Program to accommodate the physical, dietary, cultural or behavioural characteristics of the Participant

Blue Mountains

Food Services

Supporting our Community

ENROLMENT FORM