Are you a new or existing client to The Disability Trust? *
How did you hear about us?
Please note that The Disability Trust requires at least one emergency contact on file for your safety.
Dietary Requirements *
Do you give permission to give Paracetamol? *
Do you have a specific medical action plan/information? *
(Please attach if required)
I give permission for
to appear in photos for
*Identification purposes (e.g. in client files or on medication)
Media photos on websites, advertising, etc.
I am permitted to go in the water
I am not permitted to go in the water
(Please note Non swimmers will be permitted to wade in shallow water only)
A weak swimmer (comfortable/confident in shallow water but cannot swim very well)
An average swimmer (is a reasonable swimmer but not strong or confident in deep water)
A strong swimmer (very confident in deep water)
Please check which best indicates your personal situation
Lives independently or is independent in supported accommodation or with family members.
Lives in supported accommodation or with family.
Is supported fully with living arrangements
Is able to independently care for themselves in everyday life with minimal support for daily living including showering, toileting, hygiene etc
Requires some help with personal care including dressing, showering, toileting and hygiene.
Full assistance required with all aspects of personal care e.g. showering, toileting, personal hygiene and dressing
Able to eat a meal independently and choose a meal by themselves with little prompting.
May require supervision when eating and may need assistance to order meals.
Special meal requirements or requires full assistance at meal times.
Can manage spending money with little assistance.
Needs assistance to handle money to purchase items.
Money is required to be handled by support staff.
Has good social skills and follows instructions in a group environment. No behaviours of concern or challenging social conduct.
Requires supervision in the community and may need prompting to stay with the group. May display some behaviours of concern.
Has behaviours of concern and requires extra support to be able to be supported in a group environment.
IT IS ESSENTIAL THAT THE INFORMATION PROVIDED TO TRUSTED TRAVEL IS CONSISE AND COMPLETE, FAILURE TO PROVIDE DETAILED INFORMATION MAY RESULT IN PARTICIPANTS EXPERIENCE BEING COMPROMISED.
*If you select use of your NDIS plan, please fill out the below information
I do hereby agree that The Disability Trust will make a service booking
for the amount of funds required for the holiday requested. I will be forwarded a Service
Agreement and Schedule of Supports as relevant to the holiday selected.