Request for Professional Learning Workshop

Request for Professional Learning Workshop

Date of Request:
Organisation:
Contact Person:
Address for correspondence (email/street):
Phone number:
Which workshop are you interested in? Workshops are for up to 25 attendees
£ The Sway (3 hours)
£ Key Word Sign 1 day basic workshop
£ Teacher Talk 1 day
£ Other/tailored workshop request (please specify below)
Who is the workshop aimed at? e.g. parents, teachers, support staff
How many people will be attending?
What would you like to get out of the workshop? What would be a good outcome?

Would you like an assessment with recommendations Y/N

Would you like a full written report at an extra cost Y/N

Do you need a written plan for Eating, Drinking, Swallowing / Individual Transfer Mobility / Transport (Circle as appropriate)

RB person completing the form:
Quote : / Please note the quote will be provided to you once we have the completed form
Travel is charged at the hourly rate. Quotes are exclusive of GST.

Consent

I, ...... certify that I am authorised by law to consent to this referral treatment regime. I reserve the right to withdraw consent at any time without prejudice. In regards to matters of privacy Rocky Bay shall primarily follow the Australian Privacy Principles outlined within the Privacy Act 1988 and subsequent amendments. This will ensure best practice in the collection, storage and disclosure of personally identifiable information held by the organisation. Personally identifiable information shall be held in a combination of paper copies and within electronic systems, as is most appropriate to operations. Systems shall have well managed security access policies relevant to individual staff roles. I understand that with consideration to confidentiality my details might be shared with other professionals dependent on need. I understand that withdrawal of consent will result in the immediate suspension of Rocky Bay Services. Any outstanding monies remain payable.

Signed: ______Date: ______
(Client OR Authorised Representative)

Please return to Rona Dean, 13 Baling Street, Cockburn Central, 6164 / email Tel. 63994124 / Mobile 0406381782

Cancellations within 5 working days will incur the full workshop fee. Payments terms are 14 days by invoice.

FFS.15 TPS FFS Request for workshops. Written 8/4/16