NDIS Service Agreement, Term 4 2017 Section 1 - Contact Details Rainbow Club Member’s Name: Rainbow Club: ---Bexley Rainbow ClubBondi Rainbow ClubByron Bay Rainbow ClubCampbelltown Rainbow ClubCronulla/Miranda Rainbow ClubCherrybrook Rainbow ClubHornsby Rainbow ClubLiverpool Rainbow ClubMaroubra Rainbow ClubNewington Rainbow ClubOrange Rainbow ClubPenrith Rainbow ClubRevesby Rainbow ClubSeven Hills Rainbow ClubSouthern Highlands Rainbow ClubSutherland Rainbow ClubTamworth Rainbow ClubWarriewood Rainbow ClubWarringah Rainbow Club NDIS Participant Number: Participant’s parent or Guardian: Mobile: Email Address: Section 2 - Who is managing this plan? Who is managing this plan and how can we contact them ? Please choose one option. Option 1 The funding for the support of Rainbow Club membership is being managed by the member's parents (ie Self-managed plan). Option 2 The funding for the support of Rainbow Club membership is being managed by the National Disability Insurance Agency who agrees to pay Rainbow Club within 7 days of invoicing NDIA through its portal. Option 3 The funding for the support of Rainbow Club membership is being managed by a Registered Plan Management Provider who agrees to pay Rainbow Club the term fee within 7 days from the date of issue of invoice by Rainbow Club Management Provider. Plan Management Provider Contact Phone No Email Address (for invoicing purposes) Section 3 - The NDIS and this Service Agreement This Service Agreement is made for the purpose of providing Rainbow Club Membership under the participant’s NDIS plan. Section 4 - NDIS Participant’s Plan information Commencement Date of Plan: End Date of Plan: Yes - I confirm that this plan includes funds for “Community, Social and Civic Participation" Yes - I confirm that funds of $125 is available in this plan for Term 4 Rainbow Club Membership Yes - I authorise Rainbow Club to make a Service Booking on the NDIS portal for this participant for Term 4, 2017 (14/15 October to 9/10 December) Yes - I understand that Rainbow Club is restructuring its membership fee structure and that the membership fee will be $280, starting from Term 1 2018 5 - Responsibilities of the participant/participant’s representative The participant/participant’s representative agrees to: Acknowledge that membership for Term 4 is subsidised by Rainbow Club and individualised in accordance with our Swim the Rainbow program That the fee is for the full term (starting 14/15 October and ending 9/10 December 2017) Treat Rainbow Club with courtesy and respect Talk to Rainbow Club Committee Member if the participant has any concerns about the supports being provided Give Rainbow Club the required notice if the participant needs to end the Service Agreement (see ‘Ending this Service Agreement’ below for more information), and Let Rainbow Club know immediately if the participant’s NDIS plan is suspended or replaced by a new NDIS plan or the participant stops being a participant in the NDIS 6 - Responsibilities of Rainbow Club Rainbow Club agrees to: Review the provision of supports at least twice yearly Provide membership that meets the participant’s needs at a time to be agreed with the local Rainbow Club Committee Communicate openly and honestly in a timely manner Treat the participant with courtesy and respect Give the participant information about managing any complaints or disagreements and details of the provider’s cancellation policy (if relevant) Listen to the participant’s feedback and resolve problems quickly Protect the participant’s privacy and confidential information Provide supports in a manner consistent with all relevant laws, including the National Disability Insurance Scheme Act 2013 and rules, and the Australian Consumer Law; keep accurate records on the supports provided to the participant 7 - Changes to this Service Agreement If changes to the supports or their delivery are required, the parties agree to discuss and review this Service Agreement. The parties agree that any changes to this Service Agreement will be in writing, signed, and dated by the parties. 8 - Ending this Service Agreement Should either party wish to end this Service Agreement, they must give 1 month's notice. If either party seriously breaches this Service Agreement, the requirement of notice will be waived. 9 - Feedback, complaints and disputes If the participant wishes to give the provider feedback, the participant can talk to a member of their local club committee. If the participant is not happy with the provision of supports and wishes to make a complaint, the participant can talk to a member of their local club committee. If the participant is not satisfied or does not want to talk to this person, the participant can contact the General Manager of Rainbow Club Australia at email@example.com. 10 - Agreement signatures Yes - The Participant’s Plan Manager agrees to the terms and conditions in this Service Agreement and understands that Rainbow Club is a charity that provides subsidised and individualised lessons to children with a disability to ensure that they are safe in the water.