This Respite Day Activity Program is designed to support NDIS participants to engage in meaningful
community-based activities that promote independence, social participation, life skills development,
and wellbeing. Activities are delivered either on a 1:1 basis or in a small group setting, aligned with
each participant’s NDIS goals, preferences, and support needs.

Support Objectives

This activity supports participants to:

– Increase independence and decision-making skills

– Build social and communication skills

– Access and participate in the community safely

– Develop daily living and life skills

– Enhance emotional wellbeing and confidence

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Information medical Number

Name *

First

Last

Email *

Mobile Contact

NDIS Number

NDIS FUNDING & PLAN *

• Plan Managed
• Self Managed
• NDIA Managed

Choose participant funding list

Support Needs & Safety (Essential Only)

• Personal care
• Communication support
• Mobility assistance
• High supervision needs
• Medication prompting/supervision
• Emotional regulation

Medical & Health Information (Day Program Relevant Only) Any medical conditions staff should be aware of?

• Yes
• No

Medical, Health & Allergies *

Brief Description of any medical conditions staff should be aware of, Please include allergies

Diet Requirements *

Please any diet requirements

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