Student Information for INCLUSION in Wrap Around Kids ON-LINE - NDIS Software

Student Name*

FIrst Name - Last Name

Date Of Birth

School

Teacher/ Yr Advisor

My Child Likes to

Grade*

Siblings

Name	DOB

Confirmed medical conditions

Medications	Dose1	Time1	Dose2	Time2	Dose3	Time3

Medicare No

Ref No

Valid to

Carer Allowance

Yes
No

Previous Assesments - Vision

Month/Year Assessed	Intervention	Focus of Intervention

Previous Assesments - Hearing

Month/Year Assessed	Intervention	Focus of Intervention

Previous Assesments - Psychology

Month/Year Assessed	Intervention	Focus of Intervention

Previous Assesments - Speech/Language

Month/Year Assessed	Intervention	Focus of Intervention

Previous Assesments - Occupational Therapy

Month/Year Assessed	Intervention	Focus of Intervention

Family GP/ Designated GP

Managing Professionals	Name	Address	Phone

In the list above, please include ALL the professionals for who you wish to authoress access to yours child records if you choose to use this facility. In the managing Professionals columns please indicate the individual's profession Eg - Pediatrician, Psychologist etc.

Parent's initial

Date

Phone

This field is for validation purposes and should be left unchanged.