MUDDY PUDDLES REGISTRATION

CONSENT TO EXCHANGE INFORMATION

To provide consistent and high quality support to your child, it is often necessary to discuss their support plan and progress with other people involved in the care or support of your child. Please list the people or organisations you permit us to exchange information with ("information" includes verbal, written or electronic health and development records).
Please add people you give us permission to exchange information with

CONSENT TO TAKE AND USE PHOTOS

When providing supports to your child, we may take photos of the session. Please review how we may use these photos and let us know if you consent to the use of photos in each case.
I give permission for photos of my child to be used to record their progress and appear in progress reports (seen by Muddy Puddles team and family)*

YesNo
I give permission for photos of my child to appear in the Muddy Puddles Centre (For example to demonstrate what has been happening in programs. These will be seen by other Muddy Puddles clients accessing the Centre.)*

YesNo
I give permission for photos of my child to be used for marketing and promotional purposes, including newspaper articles, flyers, presentations, social media (eg. Facebook)*

YesNo
If you answered "Yes" to allowing photos to be used for marketing purposes, do you give permission for your child's name to be used also?

First and LastnameFirst name onlyNo name to be used

SHARING YOUR CHILD'S NDIS PLAN
You can choose who you share your child's NDIS plan with, and which parts they can see.

If you choose to share your child's NDIS plan with Muddy Puddles, it will assist our team to work towards your child's NDIS goals. If you choose to share details of your child's NDIS plan budget it allows Muddy Puddles to develop a Schedule of Supports in line with your available funds and support categories.

If you choose not to share your child's NDIS plan with Muddy Puddles, then you agree to pay any out of pocket expenses incurred for services provided if they exceed the limits of your available NDIS budget. This option also limits the information we can provide to assist you with your NDIS plan reviews.
I consent to sharing the following parts of my child's NDIS plan with Muddy Puddles:

Full planGoals onlyNone
NDIS number:
NDIS plan start date:

DayMonthYear
Date
NDIS plan end date:

DayMonthYear
Date
Management type:

Self managedPlan managedAgency managed
Plan Manager name (if applicable):
Plan Manager email address for invoices:

FAMILY DETAILS
Is your child in the care of

Their parentsOther carers
If other carers, please provide details
Is there anything we need to know about your child's family situation, eg. Court orders, important support people in your child's life?
Please list the people living at home with your child (including name, age and relationship to child)

EMERGENCY CONTACT DETAILS

Please provide the contact details of someone other than the parent/carer submitting this form.
Name

First NameLast Name
Relationship to child
Home phone

Area CodePhone Number
Mobile

PARENT/CARER DETAILS