GROUP REGISTRATION & SERVICE AGREEMENTGroup Registration & Service Agreement • June 2nd, 2022
Participant Details Participant Name: Date of Birth: NDIS Number: Phone Number: Address: Email: Cultural Status: ☐ Aboriginal or Torres Strait Islander ☐ Cultural other: Gender: ☐ Female ☐ Male ☐ Self-Described (please specifiy): Pronoun Preferences: Diagnosis: Other health or medical conditions: Does the Participant have a companion card: ☐ Yes ☐ No Guardian/Plan Nominee Details Full Name: Relationship to Person: Address: Phone: Email: Funding Details ☐ Your plan is AGENCY FUNDED For those parts of your plan that are agency funded:We will invoice the NDIS directly for payment. ☐ Your plan is PLAN MANAGED Name of plan manager: Contact Details: ☐ Self Managed Will be invoiced for the term
