please let us know a bit more about you and your unique needs

Are you submitting this applicable for you or on behalf of someone else? *

For Me

For Someone Else

What is your relationship with this person you're submitting this for? *

What is their first name? *

And their last name? *

What is the age of the person who requires Active Support? *

And what is their gender? *

Male

Female

Other

Where would you like to begin your Active Support? *

Meet me at my home

Another location

What days would you prefer your Active Support? *

Unsure / I don’t mind

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Select all the apply

And how many hours per week of Active Support are you hoping for? *

3 - 7

7 - 12

12 - 20

20 - 40

What is the disability for the person seeking Active Support?

Autism

Intellectual Disability

Developmental Delay

Psychosocial Disability

Other

Are there any other unique needs we should be aware of (i.e. wheelchair access required)?

And just to confirm, your best details are:

First Name *

Last Name *

Email *

Let’s Make Fitness Accessible & Inclusive For Everybody