Registration – Kids Plus Foundation

Personal Information
Child's First Name
Surname
Gender
Date of Birth

DD
MM
YYYY
Parent / Carer 1’s Full Name
Parent / Carer 2’s Full Name
Preferred Contact Person*
Preferred Address
Street Address Suburb Postcode
Preferred Phone number*
Additional Phone number
Email*
Country of Birth
Preferred Language
Do you require an interpreter?
- No
- Yes
Please provide details for interpreter requirement
Is your child Aboriginal or Torres Strait Islander?
- No
- Yes
Do you the Parent or Primary Carer have any additional communication requirements?
- No
- Yes
Please provide details
Siblings
Click the plus icon to add additional siblings
Name Gender Date of Birth

Background Information
What age did your child reach their developmental milestones?
(in months)
Sitting Crawling Standing Walking
Equipment and Assistive Technology
including splints please list
Existing Therapy Provider
Therapy Provider Contact Details

Funding Source
Funding
NDIS Number
Please state other source
Additional Information
Do you require assistance with accommodation?
- Yes
- No
Any other information you think would be useful?
Documentation
Please attach the following recent documents
Recent Paediatrician report, NDIA Plan if applicable, Signed Privacy Form
Drop files here or

Accepted file types: jpg, jpeg, png, gif, pdf, doc, docx.
Following your registration for the Intensive Program we will send you a welcome pack and additional information about our services. How would you like this information sent to you?
- Email
- Post

Personal Information

Name	Gender	Date of Birth