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Gym & Fitness Liability Waiver
Do you have a doctor’s permit to participate in intense physical activities?

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NDIS Service Agreement

This Service Agreement is made between the Participant and the Provider - UFVRA. This Service Agreement can be made between the Participant and/or the Participant’s representative and UFVRA . The Participant’s representative can be a family member, friend, or someone close to the Participant who can manage the funding for supports

Participant's Name

Participant's Representative (if applicable)

Date of Agreement*

Review Date

Agreement Details

Participant’s diagnosis

Funded by:*

  • Agency Managed (NDIA)

  • Plan-managed

  • Self-managed

Planned Interventions & Finance

List of services - to add more simply click the + button*

Travel costing is determined via the NDIS guidelines, charged in 5-minute increments at the therapist hourly rate of $193.99 (this includes travel time and non-labour costs associated with that travel + $1.00 per allowance km for their travel distance).

Short Notice Cancellations / Missed appointments will be charged

Emergency or Disaster Arrangements

Arrangements for providing supports in the event of an emergency or disaster - to add more simply click the + button

Participant's Consent

I want to acknowledge that UFVRA  Australia / In-home & Community Care Plus has advised me of the following:

  • List

  • UFVRA  Australia / In-home & Community Care Plus’s Privacy and Confidentiality Policy

  • What type of personal information including recorded material in audio and/or visual format will be collected and for what reason and how I can have access to Participant information

  • Participant right to access or correct personal information

  • Participant right to withdraw or amend Participant consent at any time

  • Participant right and how to make a complaint about a breach of my privacy

  • UFVRA  Australia / In-home & Community Care Plus will provide an interpreter if I requested

  • UFVRA  Australia / In-home & Community Care Plus may share relevant information with other participant’s providers to meet the participant needs

  • How UFVRA  Australia / In-home & Community Care Plus will store my personal information

  • Management of my medication (if applicable)

  • UFVRA  Australia / In-home & Community Care Plus involves me in my mealtime management planning if I need mealtime management plans.

Disclosure of my personal information to:

− the NDIS Quality and Safeguards Commission, NDIA or other authorities and government agencies if required

− health professionals and other providers if needed

− other parties such as my advocate or support network if applicable

Complete Healthcare Connect Australia / In-home & Community Care Plus’s workers are authorised to use my money or other properties for the purposes listed below:

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