CONTACT DETAILS

PARENT / GUARDIAN *

RELATIONSHIP TO CHLID

MOBILE *

EMAIL *

ADDRESS *

EMERGENCY CONTACT *

RELATIONSHIP TO CHILD

HOW DID YOU HEAR ABOUT US?

STUDENT DETAILS

NAME OF CHILD *

YEAR LEVEL *

DOB *

HOW WOULD YOU DESCRIBE YOUR CHILD'S LEARNING STYLE? *

Easily Distracted Mostly Focused Highly Focused Unsure

DIAGNOSIS/ CONDITION ( eg. Sensory, Behaviour, Possible / Diagnosed / Suspected Conditions - Dyslexia, ADHD, Autism, OTHER )

COMMENTS

DOCUMENT UPLOAD - If Applicable (EG. Diagnoses, School Reports)

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SESSION DETAILS

PREFERRED DAY - 1 *

PREFERRED DAY - 2 *

PREFERRED DAY - 3

PREFERRED TIME - 1 *

PREFERRED TIME - 2 *

PREFERRED TIME - 3

EDUCATOR: Office to complete

BOOKED - DAY - TIME - LOCATION: Office to complete

NOTE: These are your days and times unless advised otherwise. You are enrolled until you advise otherwise.

PAYMENT DETAILS

PAYMENT OPTION *

INVOICE PER TERM ( eg.10 sessions per term ) DIRECT DEBIT PAYMENT PLAN ( eg. calculation 4 x Terms (40 sessions ) paid over 52 weeks a year plus a $25 set up fee ) NDIS ($450 initial fee, reports plus $150 yearly review plan - Costs per plan / goal requirement )

TERM INVOICE AMOUNT: Office to complete

DIRECT DEBIT DETAILS

ACCOUNT NAME

BSB

ACC

Preferred Weekly Budget

FREQUENCY: Weekly / Fortnightly

Preferred date to start direct debit

DIRECT DEBIT AMOUNT: Office to complete

Frequency Amount - Office to complete

NDIS DETAILS

COMPLETE IF REQUIRED

PLAN NUMBER

CONFIRMATION

Average Yearly amount ( not a contracted amount ) - Office to complete

I acknowledge by enrolling today the average yearly commitment. I am also aware I am NOT bound to a yearly contract and I am FREELY able to leave at any time with the standard 2 weeks’ notice, cleaning up any outstanding amounts (if any) and $50 exit fee.

*

By signing this form, I acknowledge the Terms and Conditions of Learning Pod Group and agree all the information is true, correct and understood. *

I allow Learning Pod Group to set up Direct Debit as per information above OR Provide an invoice *

Comments:

Signature of parent / guardian

Draw signature|Type signatureClear

OFFICE ONLY:

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