Activate Leadershipprogram 2018-09-18T01:04:37+00:00

CONFIDENTIAL APPLICATION FORM

SURNAME:*
FIRST NAME:*
PREFERRED NAME:*
DATE OF BIRTH:*
ATSI: Do you identify as an Aboriginal or Torres Strait Islander?*
YESNO
CULTURAL DIVERSITY: Were you born in Australia?*
YESNO
EMPLOYER:*
ROLE:*
ADDRESS:*
PHONE: WORK*
MOBILE*
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 PROGRAM?(E.G.TRANSPORTATION; ACCESS):*
DO YOU HAVE ANY MEDICAL CONDITIONS THAT MAY REQUIRE CONSIDERATION DURING THE PROGRAM OR THAT WE SHOULD BE AWARE OF?:*
DO YOU HAVE ANY SPECIAL DIETARY REQUIREMENTS?:*

Other:

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

Participation Commitment:

Time:

The Activate Leadership Program is a commitment of eight consecutive weeks. Weeks one and eight are full day program events, with the remaining six weeks being half day programs.

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

Costs:

The cost of the program is $895+GST payable upon acceptance into program.An invoice will be issued to participants’ employer unless otherwise agreed with the Leadership Co-ordinator.

Applicant Signature and Consent:

I understand the time commitment of the program.I understand that the cost of the program is $895+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:*