123 Magic - Intake Form

Thank you for your interest in the 123 Magic program.

To get started simply fill on the form below. Please note that all fields marked with an asterisk (*) require an answer to continue.

When: Dates for term 4 to be announced.

Time: To be announced.

Where: Windermere, 48 Webb Street, Narre Warren VIC, 3805

Cost: $20 (includes parent workbook)

RSVP: Bookings are essential to reserve your place.

If you have any enquiries about the program, please send an email to IFSGroups@windermere.org.au or call us on 1300 946 337

Participant Details

Are you submitting this form as a participant or a referrer? *

ParticipantReferrer

First Name *

Last Name *

Preferred Name

Date of birth *

Gender

Other:

Do you identify as Aboriginal or Torres Straight Islander? *

Country of Birth *

Interpreter needed? *

YesNo

Preferred Language *

Email Address *

Phone Number *

Alternative Phone Number

Address: *

Would you like to receive information about future Windermere programs via email? *

YesNo

Additional Information

Do you, or your child require any additional supports or adjustments due to disability, illness, or mental health condition? *

YesNo

If yes, please describe below: *

Is there any current or historical family violence? *

YesNo

Is there a safety plan in place? *

YesNo

How did you find out about this program?

Do you have any goals for the program?

Emergency Contact

Full Name *

Phone Number *

Relationship to Participant *

Medical Information

Do you have any allergies? *

YesNo

Please explain: *

Payment Details

Are you a concession or health care holder? *

Yes - $10.00No - $20.00

Payment *

Pay

Please enter the Customer Reference Number (CRN) on your Concession or Health Care Card *

Privacy Statement & Consent

Windermere will

collect, use and store your personal information, including health information, in order to provide services to you and/or your family
use your email address (where provided) to send you information that may be of interest to you as identified by your worker. Every communication will provide you with an opportunity to opt out. You can also opt out by contacting your worker or by emailing us at info@windermere.org.au.
not use your personal information for any other purpose without your prior consent or allowed or required by law
comply with the Privacy Act 1998 (Cth), as amended from time to time and the Health Records Act 2001 (Vic)
ensure that all personal information obtained about you will be appropriately collected, used, disclosed and transferred and will be stored safely and protected against loss, unauthorised access, use, modification or disclosure and any other misuse
use information (that does not identify you) for the purposes of research, reporting and improvement; and
in accordance with its privacy policy and the relevant privacy legislation, not disclose your personal information to others without your consent (see Release of Information form)

You have a right to request access to your client record containing your personal information and may make a request to correct/update personal information at any time. Any request to access or update your client record must be made in writing to the Privacy Officer.

When releasing information to others, Windermere will only share information that is necessary in order to provide the services that are of benefit to you, or as otherwise required by law.

For more information please see our Privacy Policy.

I have read and agree to Windermere's Privacy Policy *

Please sign here *

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Date *

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