Participant Enrolment form

Participant Enrolment form

Participant Details

Name
Name
First
Last
What is the gender of your participant?
Does the participant have Down syndrome
Are you of Aboriginal or Torres Strait Islander origin?
Do you require an interpreter?
Do you participate in other dance and/ or fitness classes or programs?
Have you attended emotion21 programs before?

Contact Details

Address
Address
City
State/Province
Zip/Postal
Primary Parent or Support Person’s Name
Primary Parent or Support Person’s Name
First
Last
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?
Secondary Parent or Support Person’s Name
Secondary Parent or Support Person’s Name
First
Last
Emergency Contact
Emergency Contact
First
Last

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?

Health and Safety - Allergies

Teaching the Participant

Section

Agreed code of conduct

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

  1. 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.
  2. Respect and follow emotion21 class rules.
  3. Attend class on time; or notify your absence through our Move Portal as per NDIS cancellation guidelines to avoid being charged any fees.
  4. 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
  • Advocacy

    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 stored and used in accord with all legislative requirements. For more information please click here.

    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.

    emotion21 will:

    • protect your privacy and confidential information
    • consult the participant and/or your parent/carer on decisions about any changes to the services provided
    • listen to your feedback and resolve problems quickly
    • treat you with courtesy and respect