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My Support Plan

My Support Plan

My Representative (if applicable)

My Secondary/Emergency Contact (if applicable)

My Likes

My Dislikes

Client Photo



Medical Contact Details

My Emergency & Disaster Management Plan


My Plan
I will need assistance in the following areas to ensure my safety in the case of an emergency

Other Emergency Phone Numbers
Police, Fire and Ambulance - 000
SES - 132 500

Swimming Profile

To ensure the safety and wellbeing of our clients, swimming activities are always undertaken at a minimum 1:1 support ratio.  

Additional comments

Swimming Waiver 

Declarations & Consents

Consent to Seek Medical Attention

Consent to Administer Medication

Consent for Future Contact

Consent to Share Information

Consent to Take, Store and Share/Publish Photography

I, the participant or representative named above, hereby give my consent for Inclusion Plus to take, display and/or share photographs and/or video of the participant for use in:

* Media releases, media articles – including newspapers, radio, television, printed publications and other organisational marketing materials

* Electronic publications and communications including Inclusion Plus social media platforms and the Inclusion Plus website

I, the participant or representative named above:

* Understand that publication of these images may result in the participant being able to be identified in connection with the images/videos published

* Authorise the use of these images without compensation to me. All prints, digital files and digital reproductions shall remain the property of Inclusion Plus Family Support Inc.

* Understand that this permission will remain valid and effective until written advice has been provided to Inclusion Plus Family Support Inc. withdrawing this authority

* Authorise for group images and group videos of the participant to be shared with other families, if a group photo is taken when attending an Inclusion Plus program


I confirm that all of the above information is true and correct as at the date of signing

Sign Here
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