Geelong Registration: Participant Details Personal Details Name of participant * First Name Last Name Program / Service you are registering for * Step Up Program Buddiup Pups Team Buddiup Mentoring and Supports Date of birth * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Participant mobile number (if applicable) Diagnosed disability NDIS participant number Health Details Are there any personal care requirements? Please outline details if required. * Any medical information or medication requirements we should be made aware of? * e.g., epilepsy, asthma, medication Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke? * Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise? * Do you ever feel faint, dizzy or lose balance during physical activity/exercise? * Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? * If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months? * Do you have any other conditions that may require special consideration for you to exercise? * Describe your current physical activity/exercise levels in a typical week by stating the frequency and duration at the different intensities. * Risk Summary / escalating bahaviour and level (high, med,low) * Actions to take with any escalating behaviours if applicable Primary Contact Details Name of primary contact * First Name Last Name Phone number of primary contact * Email of primary contact * Plan Details Plan Managed or Self Managed * Plan Self Email to send invoices to * Thank you, we’re so excited that you’ve joined Team Buddiup!
