emotion21 Enrolment Form – Inclusion Foundation

Please note the Primary Parent or Support Person will receive all email, txt communication as well as have access to the Move Portal. Do you wish for a Secondary Parent of Support Person to also receive all email/ txt communication as well as have access to the Move Portal?

Yes No

Emergency Contact Mobile

Emergency Contact Home Phone

Emergency Contact Email

Studio Locations

Please select the studio you are interested in attending.

Please select all applicable. You can view class details here.

First Aid Permission

In case of an emergency do you give permission for us to administer first aid or call an ambulance if deemed to be a medical emergency?

Yes No

Health and Safety - Allergies

Please list any allergies the participant may have and let us know how they would react and the most appropriate treatment to administer

Please list any regular medication currently taken

Please list any serious illnesses or injuries, both past and present

Teaching the Participant

Please list any information that could assist us in teaching the participant such as motivators, behaviour strategies, communication, and signs.

ParagraphPlease share with us what you would like to achieve at emotion21 in the year ahead? If you are funded by the NDIS, what goals are listed in your NDIS plan that we could work with you to achieve?

What support from emotion21 do you need to achieve these goals

Section

Agreed code of conduct

By enrolling in the emotion21 program you agree to the following standards of behaviour.

Behave in a way that is aligned to emotion21’s values; Be kind, Act with kindness, Show courage, Open heart and mind, see the person, always.
Respect and follow emotion21 class rules.
Attend class on time; or notify your absence through our Move Portal as per NDIS cancellation guidelines to avoid being charged any fees.
Support e.motion21 policies and procedures.

Statement of Commitment to Child Safety emotion21:

has zero tolerance for child abuse
actively works to listen to and empower children
has systems to protect children from abuse, and will take all allegations and concerns very seriously and responds to them consistently in line with the organisation’s policies and procedures
is committed to promoting physical, emotional and cultural safety for all children
is committed to providing a safe environment for all children

At any stage during your interaction with e.motion21 should you wish to use the services of an advocate please contact the Office of the Public Advocate on 1300 309 337 or via their website on www.publicadvocate.vic.gov.au

The Victorian Public Advocate is empowered by law to promote and safeguard the rights and interests of people with a disability.

There are a number of other specific advocacy agencies funded through the OPA. They can be found on the Department of Human Services, Victoria website – please click on the link below: http://www.dhs.vic.gov.au/for-service- providers/disability/protecting-rights/disability-advocacy/disability-advocacy- organisations

emotion21 is committed to ensuring the privacy of all participants, staff and volunteers. All information is stor

Feedback, Complaints, Disputes and Resolution Process

emotion21 welcomes feedback from the participant or participant’s representative and seeks to resolve any concerns a participant may have, in a timely and professional manner.

If the participant wishes to give e.motion21 feedback or has a dispute, the participant can talk to their Volunteer Site Coordinator or a staff member at Kew Head Office. Or complete our online Feedback Form here.

If the participant is not satisfied with the outcome they can contact emotion21 CEO at the office. ‘Alternatively, the Participant can make contact with the Office of the Disability Service Commissioner’ on 1800 677 342, or visit the ODSC website on www.odsc.vic.gov.au for further information.