Expression of Interest

Participant's first name*

Participant's last name*

Preferred name

Gender*

Date of birth*

Email*

Participant mobile number (if applicable)

Street address*

Suburb / City*

State*

Post code*

Are you completing this form for yourself or on behalf of another person?

Should we contact someone else to discuss further?

Please provide details of any disability, mobility and/or medical conditions*

Do you have an NDIS Behaviour Management Plan?

Do you use a wheelchair?

Do you have a High Intensity Care Plan?

Please upload your NDIS Plan Goals

Choose a file (PDF, Word or photo, up to 10 MB)

NDIS plan start date

NDIS plan end date

How is your NDIS plan managed?*

Please tick the programs you are interested in attending

All programs are subject to availability.

Which day/s would you like to attend Sunshine Butterflies?

What type of after hours support are you looking for?

Which day/s would you like after hours and/or community support?

Which sessions or therapies are you interested in?

Was there anything else you wanted to tell us?

How did you hear about us?*

1. Participant / Member details