ReferralActive Inclusive Programs "*" indicates required fields Step 1 of 3 - Details of Person 0% Participant InformationFull Name* Given Name Surname Date of Birth DD slash MM slash YYYY NDIS Number* Parent / Guardian InformationFull Name Given Name Surname Primary PhoneAlternate PhoneEmail Enter Email Confirm Email RelationshipE.g. Mother / Father / Legal Guardian Consent Form - Authority to Collect, Use and Disclose Client InformationPersonal information collected by Active Inclusive is protected by the Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) (Privacy Act). Personal information is any information or an opinion that identifies you and includes sensitive and health information. (Please refer to Fact Sheet for definitions) The primary purpose for collecting personal information from you is to: determine eligibility for services and/or waitlist management provide services, including planning, funding, monitoring and evaluating our services report to government or other funding bodies how funding is used, take photographs and videos for therapeutic and marketing purposes respond to your feedback or complaints, and answer your queries. *Please note that Active Inclusive is required to release information about service users (without identifying you by full name or address) to the Disability Services Commission and to the Australian Institute of Health and Welfare, to enable statistics about disability services and their clients to be compiled. The information will be kept confidential. This information is used for statistical purposes only and will not be used to affect your entitlements or your access to services. As a user of National Disability Agreement services you have the right to access your own files and to update or correct information included in the Disability Services National Minimum Data Set collection. Active Inclusive will not disclose/use information about you for any secondary purpose. (Please refer to Fact Sheet for definitions) unless: You have consented to the use or disclosure; or You would reasonably expect Active Inclusive to use or disclose the information for the secondary purpose as it is directly related to the primary purpose; or The use or disclosure of the information is required or authorised by or under an Australian law or a court/tribunal order; or Active Inclusive reasonably believes the use or disclosure is necessary to lessen or prevent a serious threat to life, health or safety of an individual or to public health and safety; or Active Inclusive has reason to suspect an individual may have done something unlawful or engaged in serious misconduct that relates to Active Inclusive functions or activities; Active Inclusive reasonably believes that the use or disclosure is reasonably necessary to assist another person to locate a person reported as missing. Consent to receive communication I do not give Active Inclusive authority to send me information about services via a Newsletter I do not give Active Inclusive authority to contact me to advise me of service related opportunities Select AllConsent*I give authority for Active Inclusive; to collect, store, use and disclose personal and sensitive information, including health records, for the primary purpose of service provision and directly related needs in accordance with the Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) whilst I/we remain a client of Active Inclusive. If my/our circumstances change I agree to notify Active Inclusive as soon as practicable. By checking this box, I hereby agree to the privacy terms above.CommentsThis field is for validation purposes and should be left unchanged.
