Land 2 LAN Combat (Guys Night)

5pm-9pm Friday 17th July

Get together with the guys for TCG, nintendo switch, playstation, pizza, pool and more!

Name Of Person Filling Out Form *

Relation to Participant: *

First Name *

Last Name *

I would like to attend *

Individually (with a support worker to myself)At a 1:3 Ratio (with a support worker to assist and support myself and 2 others)

We recommend individual supports for anyone under 18, anyone that may require assistance with feeding, toileting, medication, or anyone who does not wish to attend for the whole evening.

My Allergies Are: *Please make EXTRA note of any anaphylaxis

Dietary Requirements

Gluten FreeLactose FreeVegetarianVeganOtherNone

Please Specify *

My Support Facilitator is: *

Amy KominkovskiDylan KlohkMacey CerasaniMitchell SmithRenee JolleyScott BrancourtTristan AgostiniAedan ChaselingMichael OxfordI only do Work PlacementI only do GroupsI only receive Social Work/ Exercise PhysiologyI only receive Support CoordinationI'm not an RLCG participant

Comments

Participant Details

Full Name

NDIS Number *

Date of Birth *

Best contact *

Address

Emergency Contact *

How is your plan managed *

Self Managed Plan Managed Agency Managed

Plan Manger Details *Please include name, contact number & email.

Support CoordinatorName, contact number & email

Plan Start Date

Plan End Date

Having difficulty completing this form? If so, please contact Michael on 0499 981 728 or email fun@rlcg.org.au

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