Application Form for SNAP Programs

______

Type of service required eg Respite, Camp, Community Access

On ______

Date and time (start and finish) of required service

April 10 to 12 at 21 at Baden Powell Scout

Child or Adults Name: / First / Middle / Surname
Address
Date of Birth: / Gender: / Age:
Country of Birth: / City or Town of Birth: / Aboriginal Yes/No / Torres Strait Islander Yes/No
NDIS Number (if applicable) / NDIS Line Items
Medicare Number:
Emergency Contact; / Relationship to Child or Adult
Phone: / Mobile:
Child or Adults Legal Guardian: / Is the Child or young person in Voluntary Out Of Home Care? / Is the Child or Young Person in Statutory Out Of Home Care?
Does the Child or Young person have a Caseplan: / Caseworker: / Organisation: / Contact Details:
Phone:
Email:
Does the Child or Adult have a NDIS Support Coordinator / Name / Organisation / Contact Details:
Phone:
Email:

Medical Information

Please give detailed information to enable SNAP to provide required support.

Please attach additional information if there is not enough space available on form.

Support Required / Yes / No / If YES - ProvideDetails / What Assistance / Support Is Needed
Does the person have a disability?
Does the person suffer from any medical conditions or allergies?
Does the person have any special dietary requirements?
Does the person have any food allergies?
Does the person have any behavioural difficulties?
Is there a BSP, BMP, or IPRP available? / Please provide / attach
Can the person swim 25 metres?
Has the young person had a tetanus shot? / If so, When?
Is assistance with Showering / Bathing required?
Is assistance with Dressing required?
Is assistance with Eating required?
Is assistance with Toileting required?
Are there any special requirements regardingTransportation?
Are there any other requirements that we need to know of to support this person?
(eg sleeps with light on, frightened of anything etc.)

Current Medication

Please note: All medication must be supplied in a WEBSTER PACK and given to the Support Worker when the young person is dropped off.

Does the young person take any current medication? Yes/No

If yes please fill in details below:

Name of Medication / Breakfast / Lunch / Before Bed
Time / Dosage / Time / Dosage / Time / Dosage

Authority to administer medication:

I give consent for a SNAP Support Worker to administer medication to:

______Signature

______

(Print name)Relationship

Snap Service Agreement

I ______give permission for ______

(Insert Person’s Name)(Insert Person Responsible i.e. Parent or Carer)

to attend the SNAP Service ______on ______(service requested) (date from –to)

The total cost for this service is __$______

(cost of service requested)

I understand that the child/young person or adult will be participating in a range of activities in the community.

______Date ____/_____/_____.

(Signature)

SERVICE COSTS– valid until 30/6/18

  • Community Access will be charged at hourly rate.
  • Respite and Camp Mon to Fri - $503.00 per night(ex GST)

Note: higher costs apply for1:1 and 1:2 supports. Please contact SNAP programs for the cost of these services.

  • Respite, Camp and Whipper Snapper WeekenderSat – Sun - $1296.00(ex GST) per weekend

Note: higher costs apply for 1:1 and 1:2 supports. Please contact SNAP programs for cost of these services

Payment isrequired before the commencement of services. NDIS clients will be service booked prior to commencement.

All Cancellations will incur a 50% cancellation fee

Please make all payments to SNAP Programs Limited (ABN) 36 155 441 357

  • Cheque or Money Order – mail to: PO Box 2436, Dangar NSW 2309
  • Electronic transfer to National Australia Bank BSB: 082-514 Acct No: 129472797

Please include your invoice number on remittance and email to:

Camp Transportation – A fee of $10.00 per person is payable on pick up for any child requiring transport to and from camp.

SNAP Programs Limited l ACN 155441357

Phone 0448606789 l Fax 02 49430114 l Po Box 2436 Dangar NSW 2309

14 November 2017Page1 of 4