Dinner Out
Warilla Sporties
6pm - 9 pm
Friday 5th January 2024
First Name
*
Last Name
*
Mobile Phone Number
*
This session will be run at a cost of approx. $79.45 to the NDIS plan (exlcuding kilometres)
*
I agree for this to be added to a Schedule of Supports for the Summer Program.
Signature
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Do you currently receive Support Work from Real Life Assistants?
Yes
No
My Support Facilitator is
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Amy Kominkovski
Macey Cerasani
Nicole Eades
Renee Jolley
Scott Brancourt
Tristan Agostini
Michael Oxford (Groups Facilitator)
Please Include your NDIS Number, Date of Birth, Plan Dates and Plan Manager (if applicable)
*
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