Pegasus Expression of Interest Form
All information collected in this expression of interest form is completely cofidential and will not be shared or accessed outside of key Pegasus staff. Google Forms responses are stored in a worksheet that can only be accessed through a Google account login. For more information, please contact programs@pegasusact.com.au
Important information before applying
Pegasus , RDA coaches will review your expression of interest and if you do not have a condition that prevents you from participating we will place you on our waiting list we may also contact you to undertake an assessment.

When a vacancy arises, one Program Coordinator will contact you, and make you an offer for placement. We will provide you with a quote (Schedule of Supports), a Service Agreement, and all other forms and information.

There are some contraindications and conditions that may prevent you from participating. If you have any of the conditions listed below, riding may not be a suitable activity for you:

-Weight close too and in excess of 60kg for ambulant riders, and 32kg for participants requiring lifting. (this apply to riding program only).
-Severe behavioural disorders characterised by frequent aggressive episodes resulting in safety concerns to self or others
-Uncontrolled seizures – ie tonic clonic type occurring more than once a week.
-Extremely poor head control
-Excessive, chronic and/or recurring pain, especially as a result of physical activity
-Pathological fractures – ie osteogenisis imperfecta, severe osteoporosis
-Acute stage rheumatoid arthritis or juvenile rheumatoid arthritis
-Open pressure sores or wounds
-Unstable spine, including the following conditions, recent spinal injury and/or surgery, atlanto-axial dislocation, spondylolisthesis, acute disc herniation
-Spinal fusion with rod type internal fixation – ie Harrington or CD rods
-Severe fatigue related conditions – ie multiple sclerosis, muscular dystrophy ABI
-Severe clotting related blood disorders, ie haemophilia and/or medication/treatments which cause clotting related disorders such as heart conditions/chemotherapy.
-Degeneration/dislocation of the hip joint
Participant details
Participant full name
Your answer
Date of Birth
MM
/
DD
/
YYYY
School (if applicable)
Your answer
Height (cm)
Your answer
Weight (kg)
Your answer
Do you have an NDIS plan?
Do you have NDIS funding for Social and Community Participation included in your plan?
Participant diagnosis (please be specific):
Your answer
Disability Classification
If other, please provide details
Your answer
Please note any Behavioural , medical or other conditions , and current medication
Your answer
Parent(s)/guardian name
Your answer
Address
Your answer
Phone 1
Your answer
Phone 2
Your answer
Email address
Your answer
Emergency contact name and details
Your answer
Programs
What programs are you interested in?
What days and times are you available?
Mobility
Is the participant able to walk independently?
Do they use a wheelchair?
If walking, do they have unstable/unsteady gait?
Can they sit astride?
Can they sit unsupported?
Communication
Is the participant
If non-verbal, please specify current methods of communication.
Your answer
Can they follow instructions?
Any notes or comments about communication?
Your answer
Are they being treated by Allied health professionals ? Please Specify
Your answer
Other information
Is there any other relevant information that you would like us to be aware of?
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy