Therapy Intensive Staff Details Form

Date form Completed:*
DD slash MM slash YYYY
Name:*
Therapy Intensive attending:*
Current Workplace
APRHA Registration Number
Professional Indemnity Insurance Provider Number
Contact Details
Primary Phone Number:*
Secondary Phone Number:
Email:*
Address:
Emergency contact details
Name:*
Relationship to you:*
Phone Number:*
Email:*
Medical information
Do you have any medical conditions that we need to be aware of? If yes please describe below:
Does you have any allergies, if yes please fill table:
Allergy
Reaction
Treatment
Do you have any dietary needs, restrictions or preferences?*
Do you take any medications that we need to be aware of?
Medication Name
Time Taken
Dose
About You
Shirt Size:*
Swimming Ability:
On some of our camps we have therapy dogs in training who also attend. Do you have allergies or are you fearful of dogs? Please comment below:*
Photo/Video Consent
I hereby give my permission to the staff of Calm and Connected to make photographic, audio, or visual recordings of me while attending Calm and Connected’s Therapy Intensive Programs. Photos/Video of me may be used as indicated below. This consent if valid for 5 years and I understand that I can notify Calm and Connected of change in consent at any time.
To make a personal documentary history for the children’s camp experience (each child is given copies of photos taken on the trip).*
- Yes
- No
For photos to be used on Calm and Connected’s website and marketing materials to support the description of their programs*
- Yes
- No
To be uploaded on Calm and Connected’s social media*
- Yes
- No
Name:*
Date:*
DD slash MM slash YYYY
Please upload a copy of your Working With Children Check*
Max. file size: 128 MB.
Please upload a copy of your NDIS Orientation Certificate*
Max. file size: 128 MB.
Please upload a copy of your NDIS Worker Screening Check*
Max. file size: 128 MB.
Please upload a copy of your Police Clearence*
Max. file size: 128 MB.
Please upload a headshot photo of you (to be sent to families in your group)*
Max. file size: 128 MB.
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Therapy Intensive Staff Details Form

Contact Details

Emergency contact details

Medical information

About You

Photo/Video Consent

Newsletter