Enrolment and Service Agreement

Please note each year you will be required to fill out an enrolment and service agreement as your details and/or our terms and conditions may have changed. If we do not have an enrolment form for you, unfortunately you will not be able to participate in class due to regulations.

Contact Details

Primary Carer *

Phone/Mobile *

Your Address *

Country

City

State

Zip code

Secondary Emergency Contact

Phone/Mobile

Your primary email address and Facebook will be used as the main communication channel for e.motion21 to keep in contact and share information. Please ensure this email is checked regularly and “like” facebook/emotion21.

Primary email *

Secondary email

Have you attended e.motion21 programs before? *

Yes

What have you achieved since originally enrolling in e.motion21?

What do you like about the e.motion21 programs?

What would you suggest should change in the e.motion21 program?

What other programs and/or events would you like e.motion21 to run?

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

If you have ticked ‘NO’ above, you are required to ensure that you or a nominated Guardian is readily available at each class to take the appropriate action.

I agree

Guardian Name *

Health and Safety - Allergies

e.motion21 has a nut free policy at all of our classes and performance venues. Participants, parents and e.motion21 staff are prohibited to bring any food that contains nut products to these venues. Although there is a prohibition on nut products being bought to venues, e.motion21 takes no responsibility for any pain, suffering, loss or damage caused by the prohibition being breached.

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.

What would you like to achieve at e.motion21 in the year ahead?

What support do you need to achieve these goals?

Is there anything that you would like to make e.motion21 aware of that will further assist us?

Agreed code of conduct

By enrolling in the e.motion21 program you agree to the following standards of behaviour.

Behave in a way that is aligned to e.motion21’s core values of care, fun, learn and respect and follow e.motion21 class rules.
Attend class on time; SMS or email the office when unable to attend, giving at least 24 hours’ notice.
Support e.motion21 policies and procedures.

Statement of Commitment to Child Safety

e.motion21:

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

e.motion21 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

e.motion21 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 e.motion21 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.

e.motion21 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

Photographs, video and film footage and audio recordings

Consent for e.motion21 to take and use photographs, video and film footage and audio recordings *

I hereby give permission for e.motion21 to take and use the multi-media as per below

I hereby do not give permission for e.motion21 to take and use the multi-media as per below

e.motion21’s vision is to enhance lives and change perceptions of Down syndrome within society through dance, fitness and performance. The use of photography, video, audio and film will be in accordance with this vision and e.motion21's core values of care, fun, learn and respect.

Under the Information Privacy Act, photographs, videos, film and audio recordings are classified as "personal information". The purpose of this consent form is to comply with the privacy legislation and enable e.motion21 to take and store photographs, video, film and audio recordings as part of its programs and the promotion thereof.

Multimedia consent

By ticking the relevant boxes below and signing this section, I agree that e.motion21 may, at its discretion, use photos, videos, voice recordings, the written version of the words spoken in videos, film and voice recordings and identify the individual using their first name only.

Payment Terms & Fees

When you enrol the participant with e.motion21, you are making a financial commitment to pay fees for each term, plus an annual concert contribution of $35 which will be added to term 2 fees.

e.motion21 classes are calculated at: (non NDIS fees)

$17 per class
$12 for every second class you do eg. Performance Program; Beat Fit^TM; second venue

Payments will be processed on the second working day the week prior to each term commencing. Unless payment is received in full prior to each term commencing, an individual will not be able to participate in the program. If you have fees outstanding for prior terms these will automatically be processed on the second working day, the week prior to each term commencing. $20 per term administration fee (non refundable) applies for processing credit card payments or transfers to e.motion21 bank account. A $25 per term late fee applies to payments made past invoice due date.

e.motion21’s programs are registered with the NDIS to provide the supports of “Community Participation in a Group Activity”. NDIS fees will be calculated in accordance with current rates as determined by the NDIA. The NDIS price for services is set by the NDIA and is reviewed annually. e.motion21 reserves the right to change the price of its services in accord with any changes made by the NDIA to service pricing.

If a class is cancelled by e.motion21, for whatever reason, a credit note will be processed for that day and will therefore be deducted off your next terms’ fees. A minimum of 24 hours’ notice will be given if a program has to be cancelled.

Absences

Please note if the participant is unable to attend the full term for whatever reason, you will need to email the office at info@emotion21.org.au the details 10 working days prior to the payment being direct debited and/or committed so that you can be charged accordingly. No refunds or credits are given for unforeseen circumstances that resulted in a cancellation and/or individual classes missed due to illness, injury or any other reason. This fee may be waived if e.motion21 is given at least 24 hours notice of an intended absence. This notice must be given in writing with an email to info@emotion21.org.au. In the event of a participant withdrawing from or taking a break from emotion21, please email the details to info@emotion21.org.au. If payment has been processed, a credit note will be issued. No cash refunds will be processed. In exceptional circumstance, the parent/carer should contact the CEO to discuss arrangements. Please note: for NDIS absence please see funding section of this form.

Payment Options: *

1. Direct Debit details

2. Funding

Note: If you pay by credit card and or cheque you will incur a $20 admin fee per term.

1. Direct Debit details:

I authorise e.motion21 Inc to direct debit my bank account as instructed below

Bank Account Name *

BSB *

(6 digits only)

Bank Account Number *

2. Funding:

Note: If you pay by credit card or cheque you will incur a $20 admin fee per term.

Funding Type

NDIS

Other (Non NDIS)

NDIS type

Direct

Intermediary

Self-managed

Name of organisation *

Email address of organisation *

NDIS Number *

Plan start date *

Plan end date *

The NDIS and this Service Agreement

This Service Agreement is made for the purpose of providing supports under the Participants’ National Disability Insurance Scheme (NDIS) plan.

The Parties agree that this Service Agreement is made in the context of the NDIS, which is a scheme that aims to:

support the independence and social and economic participation of people with a disability; and
enable people with a disability to exercise choice and control in the pursuit of their goals and the planning and delivery of their supports.

The supports described in this Service Agreement are reasonable and necessary supports specified in the statement of supports in the Participant’s NDIA current plan (under section 37 of the National Disability Insurance Scheme Act 2013). e.motion21 will adhere to the National Disability standards.

The Participant’s NDIA plan is expected to remain in effect during the period the supports are provided; and
The Participant will immediately notify the Provider if the Participant’s NDIA Plan is replaced by a new plan or the Participant stops being a participant in the NDIA.

Changes to this Service Agreement

If changes to the supports or their delivery are required, the Parties agree to discuss and review this Service Agreement. The Parties agree that any changes to this Service Agreement will be in writing, signed, and dated by both Parties.

Ending this Service Agreement

Should either Party wish to end this Service Agreement they must give one months’ notice, in writing with an email to info@emotion21.org.au. If either Party seriously breaches this Service Agreement the requirement of notice will be waived.

Absences

An important change regarding notification of absences has also been introduced by the NDIA in the latest release of the price guide and came into effect 1 July, 2018. This cancellation policy has been adopted by e.motion21 and delineates that if a participant makes a short-notice cancellation, which is after 3pm the day before the service, the service provider will charge up to 90% of the agreed price for the cancelled appointment. This fee will be waived if e.motion21 is given at least 24 hours’ notice of an intended absence. Notified absences need to be provided in writing to info@emotion21.org.au If payment has been processed, a credit note will be issued. No cash refunds will be processed. In exceptional circumstance, the parent/carer should contact the CEO to discuss arrangements.

Please note for planned cancelations or if the participant is unable to attend the full term for whatever reason, you will need to email the office at info@emotion21.org.au the details 10 working days prior to NDIS funds being drawn down or committed so that you can be charged accordingly. No refunds or credits are given for unforeseen circumstances that resulted in a cancellation and/or individual classes missed due to illness, injury or any other reason.

Please note:

Participants will be charged the full NDIS rate and only if their package allows partial funding by NDIS they need to cover the balance.

e.motion21 will send the participant an invoice for those supports for the participant to pay. The Participant will pay the invoice within 7 days.

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Last updated: 14/12/2018 (v7)

Enrolment and Service Agreement

Participant Details

Contact Details

Site Location

First Aid Permission

Teaching the participant

Agreed code of conduct

Photographs, video and film footage and audio recordings

Payment Terms & Fees

Absences

1. Direct Debit details:

2. Funding:

Submit