State (please tick) *

Queensland

South Australia

New South Wales

Western Australia

Victoria

Northern Territory

Australian Capital Territory

Tasmania

Personal Details

Child's First Name *

Child's Medicare Number *

Child's Medicare Number on Card *

Child's Medicare Expiry Date *

Parent/Guardian Gender *

Parent/Guardian Birthdate *

Parent/Guardian Medicare NUmber *

Parent/Carers Medicare Number on Card *

Parent/Carers Medicare Expiry Date *

Email (of Guardian) *

Private Health Insurance (if applicable)

Private Health Insurance Provider (for the Child)

Private Health Insurance Number or Details (for the Child)

Private Health Insurance Provider (for the PARENT/CARER)

Private Health Insurance Number or Details (for the PARENT/CARER)

Additional Information

Are there any family, behavioural or medical conditions which we should be aware of? If the condition is not mentioned below, please state in the additional notes section below.

For Child

ADD/ADHD

Autism Spectrum Disorder

Hearing/Sight Impairment

Formal Counselling, Depression or other issues that may affect the participant on the event?

Is there any restriction on activities?

Travel Sickness

For Parent

ADD/ADHD

Autism Spectrum Disorder

Hearing/Sight Impairment

Formal Counseling, Depression or other issues that may affect the participant on the event?

Is there any restriction on activities?

Travel Sickness

Additional Notes/Other

Dietary Requirements

For Child

For Parent

Additional notes for child

Additional notes dietary for parent

Who were you referred by? (e.g. school/organisation)

How did you hear about bootcamp? *

Have you been to this venue before *

Yes

In case of an emergency or a serious injury, do you give us permission to call emergency services (e.g. ambulance/police/fire department) as the first point of contact?

Emergency Contact 1

Relationship to Child/Parent/Carer *

Emergency Contact 2

Relationship to Child/Parent/Carer *

Child Protection and Safety Information

Empowered Therapy and Training in conjunction with Kool Kids Tutoring is committed to the safety and wellbeing of all children and young people involved in our events. To ensure that children and young people are kept safe from harm, our staff and volunteers are required to possess a current working with children check (e.g. Blue Card); agree to adhere to a code of conduct when working with children and undergo training in child safety. We take child protection and safety matters seriously and consequently has policies and procedures in place to ensure that your child has the best possible experience with us.

Do you give Empowered Therapy and Training in conjunction with Kool Kids Tutoring permission to share video footage or photographs of your child and the adult taken during the bootcamp in both print and digital formats, including our websites? *

Yes, for Child

No, for Child

Yes, for Parent

No, for Parent

Do you consent to ETT Staff continuing contact with you after the bootcamp to keep you updated about future events? *

Yes, for Child

No, for Child

Yes, for Parent

No, for Parent

Do you give Empowered Therapy and Training in conjunction with Kool Kids Tutoring permission to transport your child and the adult to and from the venue? *

Yes, for Child

No, for Child

Yes, for Parent

No, for Parent

Having my name inserted in minutes of meetings *

Yes, for Child

No, for Child

Yes, for Parent

No, for Parent

Having my name included in committe membership lists *

Yes, for Child

No, for Child

Yes, for Parent

No, for Parent

My birthday announced in newsletters *

Yes, for Child

No, for Child

Yes, for Parent

No, for Parent

My photograph displayed internally on noticeboards *

Yes, for Child

No, for Child

Yes, for Parent

No, for Parent

My name mentioned in relation to activities of the organisation in the newsletter *

Yes, for Child

No, for Child

Yes, for Parent

No, for Parent

My name and photograph appearining in the local paper in relation to activities of the organisation *

Yes, for Child

No, for Child

Yes, for Parent

No, for Parent

My name and photograph appearing in organisational promotional material and on the organisation's website *

Yes, for Child

No, for Child

Yes, for Parent

No, for Parent

All details contained within this referral form are considered to be private and confidential.

Responsibilities of the Provider

The provider agrees to:

1. Support the participant (child and the parent/guardian) to achieve their goals, meet their needs and requirements and sensitively respond to and support their rights to practice their cultural diversity values and beliefs.

2.Communicate openly & honestly in a manner and mode in which the participant (child and the parent/guardian) is most likely to understand, in a timely manner, and where needed, we will use Auslan and or language interpreters

Please tick the appropriate date for you and your youth

Dates *

13th-15th of September 2025

13th-15th of December 2025

Event location

The Duporth Riverside; 6 Wharf St, Maroochydore QLD 4558, Australia

ETT P/C Connection Full Payment (NDIS participants) / NDIS FUNDING

Please note the payment will be processed via NDIS funding. The price is $5,997 (non-GST)Account details: Empowered Therapy and Training BSB 484-799 Account Number: 050103977 As confirmation of payment please state the child's full name.

FREE

Please provide your billing and invoice address accurately (support coordinator, plan manager, self-administrator, etc.).

for example. :
name, email, phone number, organisation

Email referrals@empoweredtherapyandtraining.com if you have questions.

Thank you!

Please Send Invoice to:

Email of person completing this form *

Organisation email *

Organisation Phone Number *

Check to agree Cancellation, Refund, and Privacy Policy *

Yes, I Agree

Our Finance Department will be in touch with you and you're NDIS support coordinator

Parent-Child Connection Bootcamp Enrollment Form (NDIS Participant)

ABN: 55 637 079 620