STUDENT DETAILS

NAME OF CHILD *

YEAR LEVEL *

DOB *

DIAGNOSIS/ CONDITION ( eg. Sensory, Behaviour, Possible / Diagnosed / Suspected Conditions - Dyslexia, ADHD, Autism, OTHER )

DOCUMENT UPLOAD - If Applicable (EG. Diagnoses, School Reports)

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COMMENTS

SESSION DETAILS

PREFERRED DAY - 1 *

PREFERRED DAY - 2 *

PREFERRED DAY - 3

PREFERRED TIME - 1 *

PREFERRED TIME - 2 *

PREFERRED TIME - 3

PAYMENT DETAILS

PAYMENT OPTION: Enrolment fee may apply. *

INVOICE PER TERM (eg.10 sessions per term) (Payment plan welcome) Zippay or After pay NDIS - Costs per plan / goal requirement

We're dedicated to ensuring your child feels understood and we align our efforts with everyone's goals to create a customized education plan. There's a $50 enrollment fee per child, which may increase to $150 if additional reports or professional assessments from teachers, specialists, or others are needed. Our team will clarify the final fee when they contact you.

NDIS DETAILS - COMPLETE IF REQUIRED

PLAN NUMBER

CONFIRMATION

By signing this form, I acknowledge the Terms and Conditions of Learning Pod BOORN and agree all the information is true, correct and understood. *

I acknowledge by enrolling today the average yearly commitment. I am also aware I am NOT bound to a yearly contract and I am FREELY able to leave at any time with the standard 4 weeks’ notice, cleaning up any outstanding amounts (if any) and $50 exit fee.

*

I allow BOORN to set up Direct Debit as per information above OR Provide an invoice to initiate services *

Comments:

Signature of parent / guardian

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Date *

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