Friendship Bakery Participant Intake Form

This intake form is an agreement between yourself and NSW Friendship Circle Inc. ‘NSW Friendship Circle Inc’ includes The Friendship Bakery, Jewish Inclusion Project Ltd and/ or any of their associated entities/ persons and/ or agents, members or employees.

This form sets out the terms and conditions on which participants/ their parent or guardian agree to participate in activities conducted at or by Friendship Circle. Participants can only join activities conducted at or by Friendship Circle after this form has been completed. You should only sign this form if you have read and understood everything contained in this form.

Fields marked with a red asterisks are required. Please indicate N/A in any fields that do not apply.

I am completing this form: *

For myself
On behalf of someone else

If you are completing this form for someone else, please provide your details:

Your Name

Relationship to the Participant

Your Email

Your Mobile

Please enter in this format: 614XXXXXXXX

1. Participant Details

First Name *

Last Name *

Birth Date (MM/DD/YYYY) *

Please enter in this format: Month/Date/Year

NDIS Number *

Email *

Please enter the parent's/ guardian's email address if the participant does not have their own.

This email address belongs to: *

Participant
Parent/ Guardian

Mobile *

Please enter in this format: 614XXXXXXXX

Phone Type *

Please enter the parent's/ guardian's mobile number if the participant does not have their own.

This phone number belongs to: *

Participant
Parent/ Guardian

Street Address *

Suburb *

State *

Postcode *

Country *

Do the parent(s)/ guardian(s) live at this address? *

Yes
No

2. Additional Contacts

Please provide details for two alternate contacts. Contact 1 will be notified in the event of an emergency.

Contact 1 First Name *

Contact 1 Last Name *

Contact 1 Relationship to Participant *

Contact 1 Phone *

Contact 1 Email *

Contact 2 First Name *

Contact 2 Last Name *

Contact 2 Relationship to Participant *

Contact 2 Phone *

Contact 2 Email *

3. Support Coordinator Details

If you have engaged a Support Coordinator, please include their details below. Otherwise, please leave the fields blank.

Have you engaged a Support Coordinator? *

Yes
No

Support Coordinator Name

Support Coordinator Email

Support Coordinator Phone

4. Medical Information and Permissions

For our participants' wellbeing it is essential that we know about any condition, however minor, which may:

affect the ability to perform any Friendship Circle activities; and/ or
be made worse by participation in Friendship Circle activities.

Please provide details below and indicate N/A in any fields that do not apply.

Medicare Number *

Individual Reference Number on the Medicare Card *

We may require the Medicare number in case of a medical emergency.

Please describe the disability (diagnosis/ diagnoses and primary difficulties experienced) *

Please list any additional health conditions or injuries *

Please list any allergies and reactions *

Do you give permission for an antihistamine to be administered in case of an allergic reaction?

Antihistamine Permission *

Are seizures experienced? *

If yes, please send the seizure management plan to bakeryadmin@sydneyfc.org.au after completing this form.

If yes, what type of seizures are they? *

How do the seizures present? *

How are the seizures managed? *

Please list any activities that, for health reasons, cannot be participated in *

Do you work with any of the following Allied Health Professionals? *

No
Behavioural Support Practitioner
Exercise Physiologist
Occupational Therapist
Physiotherapist
Psychologist
Other

If you selected 'other', please provide details:

If you have selected any options above, please provide the practitioners name, profession and contact details. If you selected 'no', write N/A. *

The Friendship Bakery may contact the allied health professional/s where deemed relevant with regard to participating in the Capacity Building Program.

If you have selected 'Behaviour Support Practitioner' above, do you have a Positive Behavioural Support Plan?

Yes
No

The Friendship Bakery may request a copy of this plan and follow up further with the Behavioural Support Practitioner to ensure mentors are appropriately trained in providing support in line with specific behavioural needs.

Before someone can participate in Friendship Circle activities we must understand:

any medication needed during our activities; and
any medical condition that might prevent, or be made worse because of, participation in those activities.

Accordingly, to assist us in ensuring participants' safety and wellbeing, you may need to present a signed form from the treating doctor detailing medical requirements, including any medications you are currently taking. This form can either be the NSW Friendship Circle Medication Record Form or a form that your doctor has signed previously for another organisation.

By signing this form, you consent to us contacting the treating doctor to discuss any disability and/ or medical condition in order to assess the suitability to undertake the activities.

Please note: you must tell us about any new relevant disability, medical condition, illness or injury, or any relevant new treatment or medication as they occur after signing this form.

Please list any current medication, including dosage and time of day taken *

Are there any known side effects of the medication? *

Doctor's Name *

Doctor's Address *

Doctor's Phone *

Please provide any further details regarding the disability or health condition/s that may impact your participation in the Friendship Bakery Capacity Building Program:

Additional Information *

First Aid and Nurofen/ Panadol Permission

Please indicate if you give permission for us to administer First Aid and Nurofen/ Panadol if required at any of our programs.

Please also provide the full name/s and contact number/s of anyone you would like us to attempt to notify prior to administering Nurofen/ Panadol.

First Aid Permission *

Nurofen/ Panadol Permission *

Who would you like us to attempt to contact before administering Nurofen/ Panadol? *

COVID-19 Documentation

Please send through your COVID-19 vaccination certificate/ medical exemption to bakeryadmin@sydneyfc.org.au.

COVID-19 Vaccination Status *

Assumption of Risk and Waiver of Liability relating to COVID-19: click here

Do you accept the COVID-19 Agreement? *

5. Do you understand that participation in Friendship Circle activities is at the participant's own risk, and you need to accept responsibility for any injuries?

By signing this form as a participant, or parent/ guardian on behalf of your child, you:

acknowledge that there is a risk of injury arising from participation in Friendship Circle activities;
agree not to participate if there is a relevant medical condition or disability that prevents participation or would be worsened by participation;
agree that participating in Friendship Circle activities is at the participant's own risk;
agree to travelling in a private car driven by a driver approved by NSW Friendship Circle if required for participation in the activities including both travel as part of the activity and travel to and from the activity;
accept responsibility for all medical and other expenses incurred and any loss suffered as a result of any injury received or caused by participation in the activities. NSW Friendship Circle will, to the extent permitted by law, not be liable for damages or other compensation for any injuries caused or suffered by the participant or any other person as a result of participating in the activities. This means that you agree that NSW Friendship Circle is not responsible for any injuries, worsening of any condition or disability of any person, or the costs involved in any person's treatment, as a result of participation in the activities, whether a condition or treatment for that condition or disability has been disclosed in this form or not. NSW Friendship Circle is also not responsible for failing to act on any medical information provided in this form. We recommend taking out private health insurance to cover any expenses resulting from risk of injury; and
agree to NSW Friendship Circle securing necessary medical/ hospital treatment for the participant if a parent/ guardian cannot be reached in an emergency.

6. Your agreement to conditions of participation

By signing this form the participant, or nominated person completing the form on the participant's behalf, agrees that:

the participant understands the activities of NSW Friendship Circle;
if you are the parent/ guardian completing the form on behalf of the participant, you give permission for your child to participate in the activities of NSW Friendship Circle;
the participant will participate in the activities because they choose to and not because they are required to by NSW Friendship Circle;
NSW Friendship Circle can ask for further consent forms to be signed for specific activities;
The participant, or nominated person completing the form on the participant's behalf, understand that:

The participant is bound by NSW Friendship Circle's Code of Conduct and any other rules whenever they participate in Friendship Circle activities; and
if NSW Friendship Circle is not satisfied with the participant's behaviour in any way at any time, then NSW Friendship Circle may cease their participation in programs or activities;

NSW Friendship Circle may exercise all reasonable control over the participant that is necessary in the circumstances whilst they are participating in an activity;
NSW Friendship Circle may, but has no obligation to:

stop the participant from engaging in any activity;
select the participant for a different level of participation; and/ or
limit the participant's activities, based on information provided in this form or at a later time;

in some circumstances, NSW Friendship Circle may not be permitted to disclose personal (including sensitive) information about the participant to any parent/ caregiver if consent to disclosure is not provided; and
NSW Friendship Circle and its employees, volunteers and agents may use or disclose personal (including sensitive) information provided in this form or collected as part of the participant's engagement in the activities to:

organise activities;
determine suitability to take part in activities or be selected for activities as a result of any condition or disability described in Part 4 of this form;
contact and assist a doctor who is called upon to treat them; or
if required by law.

7. Permission for photos to be used for publicity

We may use photos taken of participants at our programs for publicity, e.g. in Friendship Circle newsletters, on flyers and on social media.

Do you give publishing permission? *

8. Declaration

By submitting this form you declare that:

you as the participant, or parent/ caregiver completing this form on the participant's behalf, have read and understood everything on this form; and
the details you have provided in this form are correct.

Initials of person completing form *

Date *

Timeout Warning

Friendship Bakery Participant Intake Form

1. Participant Details

2. Additional Contacts

3. Support Coordinator Details

4. Medical Information and Permissions

First Aid and Nurofen/ Panadol Permission

COVID-19 Documentation

5. Do you understand that participation in Friendship Circle activities is at the participant's own risk, and you need to accept responsibility for any injuries?

6. Your agreement to conditions of participation

7. Permission for photos to be used for publicity

8. Declaration