Participant Sign Up

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It is my plan, and I am signing up myself

About You

Title

First Name

Last Name

Your Gender

Date of Birth

About your NDIS Plan

NDIS Number

Plan Start Date

Plan End Date

Have you endorsed NDIS Superhero as your Plan Manager with the NDIS?

Yes No I don’t know

(This only applies if your current plan started after 30 October 2023 as part of the new NDIS PACE system)

Does your NDIS Plan include plan management?

Yes No I don’t know

This information can be found under Capacity Building Support – Choice and Control or Improved Life Choices

Are you currently plan managed?

Plan Managed

Yes No

Name of the plan manager

Your Contact Information

Street Address

City

State / Region

Post Code

Your Email Address

Confirm Email Address

Your Phone Number

Best time to call you

Additional Consent Details (for participant)

Please list any additional consents you wish to list on your service agreement with us. For example you may have supports in the community that you wish to be able to speak directly with us about your plan.

Or you may have a Support Coordinator or family member or nominee whom you wish to provide consent for.

You can always add or remove these at a later date by letting us know.

Do you want to add a Nominee?

Nominee

Yes No

Name

Phone Number

Do you have a Support Coordinator?

Support Coordinator

Yes No

Name

Phone Number

A copy of your monthly statement will be sent to this address.

All invoices submitted by your Support Coordinator or nominee will be considered to have your approval unless you let us know otherwise

How did you hear about us? (select one from below)

Hear about us

Social Media Post (LinkedIn or Facebook) Google Search Google Ad Facebook Ad Referred by a friend/ Word of Mouth Referred by a provider

Attach the Plan

Hear about us

Accepted file types: doc, docx, pdf, Max. file size: 10 MB.

Acceptance of Terms

I have read, understood and agree to the Service Agreement

I have read, understood and agree to the NDIS Consent Form

Participant and/or Authorised Person's Name

Signature

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