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You can contact us on +61 3 5227 8075 or cfg-admin@committeeforgeelong.com.au

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Activate Leadership Program Application Form

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    PLEASE COMPLETE THE FORM USING FIREFOX OR CHROME WEB BROWSER

    SURNAME:*
    FIRST NAME:*
    PREFERRED NAME:*
    DATE OF BIRTH:* (DD/MM/YYYY)
    ATSI: Do you identify as an Aboriginal or Torres Strait Islander?*
    YESNO
    CULTURAL DIVERSITY: Were you born in Australia?*
    YESNO
    EMPLOYER:*
    ROLE:*
    HOME ADDRESS:*
    PHONE: WORK*
    MOBILE*
    EMAIL:*
    SECONDARY EMAIL:*

    Emergency Contact Details:

    NAME:*
    RELATIONSHIP:*
    MOBILE PHONE NUMBER:*

    Employment History:

    PROVIDE A BRIEF DESCRIPTION OF YOUR EMPLOYMENT HISTORY:*

    Community:

    WHAT ARE YOUR CURRENT COMMUNITY INTERESTS(E.G. BOARD MEMBERSHIP, SCHOOL COUNCIL, SPORTING GROUPS)?:*
    WHAT TYPE OF COMMUNITY ACTIVITIES WOULD YOU LIKE TO PURSUE IN THE FUTURE?:*

    Personal:

    WHAT DO YOU HOPE TO GAIN FROM PARTICIPATING IN THE ACTIVATE LEADERSHIP PROGRAM?:*
    WHAT WILL YOU BRING (STRENGTHS AND EXPERIENCES) TO THE PROGRAM?:*
    WHO IS YOUR PERSONAL INSPIRATIONAL LEADER AND WHY?:*
    BRIEFLY DESCRIBE YOURSELF:*

    Assistance:

    DO YOU REQUIRE ANY ASSISTANCE ACCESSING THIS ONLINE PROGRAM?:*
    DO YOU HAVE ANY MEDICAL CONDITIONS THAT MAY REQUIRE CONSIDERATION DURING THE PROGRAM OR THAT WE SHOULD BE AWARE OF?:*
    DO YOU HAVE ANY DIETARY REQUIREMENTS?:*

    Other:

    WHERE DID YOU HEAR ABOUT THE ACTIVATE LEADERSHIP PROGRAM?:*

    Contact Details for Invoicing:

    NAME (Accounts):*
    EMAIL ADDRESS:*
    CONTACT NUMBER:*

    Participation Commitment:

    Time:

    The Activate Leadership Program is a commitment of eight consecutive weeks including four hour seminars once a week.

    Attendance is expected at each session to ensure that a certificate of completion can be issued.

    Costs:

    The cost of the program is $995+GST payable upon acceptance into program. An invoice will be issued to participants’ employer unless otherwise agreed with the Leadership Portfolio Team.

    Applicant Signature and Consent:

    I understand the time commitment of the program.I understand that the cost of the program is $995+GST and this will be payable upon acceptance in the program.I agree that any information I provide and photographs taken during the program may be used for promotional purposes.
    APPLICANT’S SIGNATURE:*
    DATE:* (DD/MM/YYYY)

    Committee For Geelong

    Level 1 Sally Walker Building,
    1 Gheringhap Street,
    Geelong, Victoria, 3220

    +61 3 5227 8075

    9:00am – 5:00pm
    Monday to Friday

    The Committee for Geelong acknowledges Aboriginal and Torres Strait Islander people as Australia's First Nations people and the Traditional Custodians of the land and waterways. We pay our respects to the local Wadawurrung people of this land, their Elders past, present and emerging.