All Abilities Player EOI – Point Cook Soccer Club

All Abilities Player EOI

Participant Details

Participants First Name

Participants Last Name

Preferred Name (if different)

Dropdown

Date Of Birth

Age

Address

Address Line 1

Address Line 2

City

Post Code

Any program currently attending (if applicable):

Parent/Guardian Details (if Participant is under 18)

First Name

Last Name

Relationship to participant

Phone Number (Primary Contact)

Email Address

Interest in the Program

What are you/your child hoping to gain from our All Abilities Soccer Program?

Skill Development

Physical Activity / Fitness

Social Interaction / Friendships

Teamwork Experience

Confidence Building

Having fun in a safe environment

Other (Please Specify)

Additional Supports Needs

Diagnosis or Disability (Tick all that apply or describe):

Diagnosis or Disability (Tick all that Apply or Describe):

Autism Spectrum Disorder (ASD)

Attention Deficit Hyperactivity Disorder (ADHD)

Intellectual Disability

Physical Disability / Mobility Limitations

Vision or Hearing Impairment

Speech / Language Delay

Social / Emotional Regulation Support

Other

General

Does the participant have a formal diagnosis?

Yes

formal diag description

Will the participant require 1:1 support during the session

Yes

Without recieving support from another person, does the participant have the capacity to understand the potential risks or dangers associated with an activity?

Yes

Does the participant live alone?

Yes

Does the participant understand the concept of road safety behaviours?

Yes

Does the participant have limited or no informal supports?

Yes

Can the participant effectively communicate their wants and needs to others?

Yes

Is the participant able to understand and provide consent?

Yes

Does the participant have a formal Guardian or legal decision maker appointed?

Yes

To what extent does theparticipant rely on receivingsupports and services to meettheir daily living needs?

Textarea

Would the participant’s health and safety be affected if the supports and services they usually receive were disrupted?

Textarea

Health and Medication

Does the participant have any medical conditions or illnesses? (Including a mental illness diagnosis) (if yes, provide detail below)

Yes

At the time of this risk assessment being undertaken, is the participant currently unwell? (i.e., Is the participant currently sick or do they have any injuries e.g., cuts or bruises?)

Yes

Does the participant experience seizures, or do they have a history of seizures?

Yes

Does the participant experience any involuntary movements or tics? (e.g., vocal or motor tics) (if yes, provide detail below)

Yes

Medication

Does the participant’s daily health and safety rely upon any medication being taken? (e.g., insulin) (if yes, specific details must be below)

Yes

Does the participant use an inhaler, nebuliser, or spacer?

Yes

Is the participant able to take medication orally (either via tablet or liquid)?

Yes

Allergies

Does the participant have any allergies or medical alerts?

Yes

Does the participant require an EpiPen?

Yes

Does the participant have a history of experiencing a reaction to any medications or vaccinations? (e.g., anaphylaxis to penicillin)

Yes

Does the participant experience any skin reaction to common dressings such as band-aids, micropore, etc.?

Yes

Medical Interventions

Does the participant require additional support to receive any form of medical treatment or assistance? (If yes, provide detail below)

Yes

Does the participant experience significant levels of distress in a hospital setting?

Yes

Does the participant tolerate band-aids or other dressings being applied to the skin?

Yes

Does the participant tolerate the application of cream or lotion to the skin?

Yes

Is the participant able to undergo a blood test or injection without medical intervention (e.g., sedation)?

Yes

Does the participant have a history of medical examination or procedure refusal?

Yes

Does the participant have a history of refusal to adhere and follow medical advice?

Yes

Details

Positive Behaviour Support and Behaviours of Concern

Does the participant display and engage in any behaviours of concern? (If yes, provide details below)

Yes

Does the participants current supports involve the use of Approved Restrictive Practices, as per their Positive Behaviour Support?

Yes

Does the participant engage in any self-stimulatory behaviours? (i.e., stims) (If yes, provide detail below)

Yes

Has the participant ever exercised force towards another person that caused or could have caused injury?

Yes

Do changes to the participant’s routine cause them to become distressed?

Yes

Does the participant engage in dangerous behaviours such as playing with fire or sharp objects such as knives?

Yes

Behaviours of Concern (Select any current or historic behaviours of concern)

Physical Assault (includes a wide range of behaviours such as hitting, kicking, punching, spitting, biting, pinching, etc.)

Yes

Verbal Abuse (e.g., yelling, screaming, swearing, name-calling, making threats, bullying behaviours, etc.)

Yes

Throwing objects (either generally or directly at a person, including throwing bodily fluids)

Yes

Harassment or stalking of another person/s

Yes

Intimidation of others, including making threats of harm

Yes

Self-harming or injury behaviours (includes a wide range of behaviours such as cutting, skin picking, biting self, headbanging, etc.)

Yes

Suicide risk

Yes

Absconding

Yes

Climbing

Yes

Intrusiveness

Yes

Impulsive behaviours

Yes

Refusal to follow instructions or complete tasks (non-compliance)

Yes

Withdrawal

Yes

Damage or destruction of property

Yes

Harming animals

Yes

Exploitation of others

Yes

Inappropriate sexual behaviours (includes a wide range of behaviours such as discussing inappropriate sexual topics, making obscene gestures, undressing in public, non-consensual touching of another person, exposing or touching their own body parts in a non-private setting etc.)

Yes

Self-stimulatory behaviours (includes a wide range repetitive movements like rocking, arm flapping, holding hands over their ears, echolalia, lining items up, etc.)

Yes

Details

Lifestyle, Relationships and Sexuality

Is the participant currently subject to any criminal or legal proceedings or orders?

Yes

Is the participant at risk of domestic or family violence?

Yes

Is the participant currently under a protection order? (e.g., AVO, DVO)

Yes

Is the participant at risk of exploitation by others? (Including physical, emotional, and financial exploitation)

Yes

Are there concerns from the participants’ supporters regarding any members of the participant’s social networks?

Yes

Does the participant understand the concept of ‘Stranger Danger’?

Yes

Is the participant exhibiting signs of self-neglect?

Yes

Does the participant display hoarding behaviours?

Yes

If the participant hoards items, do the collected items pose a potential fire risk?

Yes

Details

Mobility and Manual Handling

Does the participant use any aids or equipment to assist their mobility? (If yes, provide detail below)

Yes

Is the participant able to independently move around their home?

Yes

Is the participant able to independently move about in the community?

Yes

Are there current concerns regarding the participant’s ability to balance?

Yes

Does the participant regularly stumble, trip over, or bump into things?

Yes

Is the participant considered to be a ‘falls risk’?

Yes

Does the participant require any manual transfers? (If yes, provide detail below)

Yes

Details

Declaration and Acknowledgment

I understand that any identified high-risk concerns must be reported to Point Cook Soccer Club immediately for review and appropriate action prior to the commencement of training.

I confirm that the information provided is true and accurate to the best of my knowledge. I understand that this form serves as an expression of interest only and does not guarantee placement. Point Cook Soccer Club will contact me with further information.

Parent/Guardian Name (or Participant if over 18):

Parent/Guardian Name

By submitting this form, I acknowledge and agree to the declaration above.

I Acknowledge