NDIS Register Your Interest

Participant Details

First Name*
Please enter your first name.
Please enter your first name.
Last Name*
Please enter your last name.
Please enter your last name.

Date of Birth*

Day
  • - enter the day -
  • 1
  • 2
  • 3
  • 3
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 16
  • 17
  • 18
  • 19
  • 20
  • 21
  • 22
  • 23
  • 24
  • 25
  • 26
  • 27
  • 28
  • 29
  • 30
  • 31
Please enter the participant's date of birth
Please enter the participant's date of birth
Month
  • - enter the month -
  • January
  • February
  • March
  • April
  • May
  • June
  • July
  • August
  • September
  • October
  • November
  • December
Please enter the participant's date of birth
Please enter the participant's date of birth
Year
Please enter the participant's date of birth
Please enter the participant's date of birth
Street Address*
Please enter the participant's street address.
Please enter the participant's street address.
Suburb*
Please enter the participant's suburb.
Please enter the participant's suburb.
Post Code*
Please enter the participant's post code.
Please enter the participant's post code.
State*
  • - select an option -
  • Victoria
  • Queensland
  • New South Wales
  • South Australia
  • Tasmania
  • Western Australia
  • Northern Territory
  • Australian Capital Territory
Please select the participant's state.
Please select the participant's state.
Mobile Phone
Please enter the participant's mobile phone number.
Please enter the participant's mobile phone number.
Home Phone
Please include the area code
Field is required!
Field is required!
Email
Please enter the participant's email.
Please enter the participant's email.
Is the person filling in this form the participant?*
Please answer the question.
Please answer the question.

Parent/Guardian

For participants under the age of 18 years of age, under guardianship or in the care of family or caregivers please complete below
First Name
Please enter your partner's first name.
Please enter your partner's first name.
Last Name
Please enter your partner's last name.
Please enter your partner's last name.
Relationship to Participant
Field is required!
Field is required!
Mobile Phone
Please enter your partner's mobile phone number.
Please enter your partner's mobile phone number.
Work Phone
Please include the area code
Field is required!
Field is required!
Email
Please enter your partner's email.
Please enter your partner's email.

Health Information

Medical Conditions

Disability / Medical Conditions including any diagnosis if relevant*
Please give us a brief description, you can give us more detailed notes over the phone
Please enter the disability/medical conditions.
Please enter the disability/medical conditions.
Participant Strengths/Capabilities*
Please give us a brief description, you can give us more detailed notes over the phone
Please enter the participant strengths/capabilities.
Please enter the participant strengths/capabilities.
Hobbies, interests, passions, mobility status, developmental milestones (fine and gross motor skills), personality traits*
Please give us a brief description, you can give us more detailed notes over the phone
Please fill in details.
Please fill in details.

Position Information

NDIS Plan

Plan Type*
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!

Registration Groups

Look on our website for a description of the registration groups https://www.alhca.com.au/ndis/
Which registration groups would you like?
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Please give a description of the support required*
Please give us a brief description, you can give us more detailed notes over the phone
Please enter details.
Please enter details.

Required Hours*

Let us know what hours you would like support.

Monday

Shift 1 Start Time
Field is required!
Field is required!
Shift 1 Finish Time
Field is required!
Field is required!
Shift 2 Start Time
Field is required!
Field is required!
Shift 2 Finish Time
Field is required!
Field is required!

Tuesday

Shift 1 Start Time
Field is required!
Field is required!
Shift 1 Finish Time
Field is required!
Field is required!
Shift 2 Start Time
Field is required!
Field is required!
Shift 2 Finish Time
Field is required!
Field is required!

Wednesday

Shift 1 Start Time
Field is required!
Field is required!
Shift 1 Finish Time
Field is required!
Field is required!
Shift 2 Start Time
Field is required!
Field is required!
Shift 2 Finish Time
Field is required!
Field is required!

Thursday

Shift 1 Start Time
Field is required!
Field is required!
Shift 1 Finish Time
Field is required!
Field is required!
Shift 2 Start Time
Field is required!
Field is required!
Shift 2 Finish Time
Field is required!
Field is required!

Friday

Shift 1 Start Time
Field is required!
Field is required!
Shift 1 Finish Time
Field is required!
Field is required!
Shift 2 Start Time
Field is required!
Field is required!
Shift 2 Finish Time
Field is required!
Field is required!

Saturday

Shift 1 Start Time
Field is required!
Field is required!
Shift 1 Finish Time
Field is required!
Field is required!
Shift 2 Start Time
Field is required!
Field is required!
Shift 2 Finish Time
Field is required!
Field is required!

Sunday

Shift 1 Start Time
Field is required!
Field is required!
Shift 1 Finish Time
Field is required!
Field is required!
Shift 2 Start Time
Field is required!
Field is required!
Shift 2 Finish Time
Field is required!
Field is required!
Will this be the same time each week on a regular basis?*
Please answer the question.
Please answer the question.
Are you flexible with the days and times required?*
Please answer the question.
Please answer the question.
Is this position ongoing?*
Please answer the question.
Please answer the question.
Will there be any driving required?*
Please answer the question.
Please answer the question.
Is there a Behaviour Support Plan in place?*
Please answer the question.
Please answer the question.
If yes, please list the behaviours of concern and the authorised restrictive practices invovlved
Please give us a brief description, you can give us more detailed notes over the phone
Field is required!
Field is required!

Confirmation

I confirm that all information completed within my Registration form is true and accurate.*
Please confirm.
Please confirm.