My full name is *

First Name

Last Name

I was born on *

MM

DD

YYYY

My home address is *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

My primary contact is *

First Name

Last Name

Phone *

(###)

###

####

My emergency contact is *

First Name

Last Name

Phone *

(###)

###

####

I receive funding from the NDIS *

Yes

No

I will use my NDIS plan to pay for the activity *

Yes

No

My NDIS plan start date is *

MM

DD

YYYY

My NDIS plan end date is *

MM

DD

YYYY

My goals for this activity are *

To meet like minded people

Improve my sporting skills

Watch heaps of live sport

Practice my independent living skills

All of the above

Other

I have a Companion Card *

Yes

No

I have a Concession card *

Yes

No

I have a Myki card *

Yes

No

I am happy to have my photo taken by Fit to play and shared on social media *

Yes

No

I am happy for Fit to play to send me cool activities that might interest me

Yes

No