Participants Registration

To register, please complete the form below.

PARTICIPANT’S REGISTRATION

PERSON MAKING THE REQUEST

First Name

Last Name

Date of Request

Relationship to Participant

Self-referral by participant

Support Coordinator

Participant's representative

LAC

External service provider

PARTICIPANT

First Name

Last Name

Participant's NDIS number

Participant's Email

Participant's Date of Birth

Participant's Phone

(###)

###

####

NDIS Plan Start Date

NDIS Plan End Date

Participant's Postal Address

PARTICIPANT'S REPRESENTATIVE OR NOMINEE

First Name

Last Name

Relationship to Participant

Representative/Nominee Postal Address

Representative/Nominee Phone

(###)

###

####

Representative/Nominee Email

SUPPORT COORDINATOR (If applicable)

First Name

Last Name

Support Coordinator Organisation

Support Coordinator Phone

(###)

###

####

Support Coordinator Email

PLAN MANAGEMENT ADMINISTRATION

Authority to Sign Service Agreement

OR download the PDF and send it to us via post or email.

Download the ‘Request for Shine Plan Management Services PDF Form’

DOWNLOAD REQUEST FORM

Email

Post

support@shinepm.com.au

PO Box 124
Applecross WA 6953

Please download our Provider Payment Guide to assist you with receiving your payments.

DOWNLOAD PAYMENT GUIDE

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Participants Registration

To register, please complete the form below.

The Shine PM team

OR download the PDF and send it to us via post or email.

Please download our Provider Payment Guide to assist you with receiving your payments.

Trust Shine Plan Management to walk alongside you. Contact our friendly team today.

Have a query? Let’s talk

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