NOMINATION FORM - Richmond Emerging Aboriginal Leadership (REAL) Program
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KGI REAL Determined Program Dates
  • July 2019:   *NAIDOC Program in Melbourne* Sunday 30th June - Friday 5th July
  • September 2019:   Sunday 22nd - Thursday 26th

Thank you for nominating your student for the The Korin Gamadji Institute’s ‘Richmond Emerging Aboriginal Leadership Program’.

REAL Determined is an intensive program delivered during the Victorian school holidays focusing on KGI’s pillars; Culture & Connection, Growth & Wellbeing, Empower & Impact. The program is aimed at Indigenous youth aged 14-16, who have shown interest in their schooling and community and are nominated by their schools based on their engagement and attendance.

Throughout the program participants gain a better understanding of the role they can play in their community, increase self-confidence and cultural pride, and a build connection to other Indigenous youth. Participants are supported by KGI crew comprising of KGI Program Alumni and staff who are passionate about inspiring young Indigenous people.

This program is all-inclusive and costs are covered by KGI.

Any questions regarding the program please contact Thara Brown (Program Manager) tbrown@kgi.org.au or Tahlia Biggs (Program Coordinator) tbiggs@kgi.org.au
 
PARTICIPANT PERSONAL DETAILS
Firstname *
Surname *
Pronouns *
Address *
Mob/Country/People *
City *
State *
Postcode *
Phone *
Email *

DOB *
Gender *
Year Level *
School *
Region *
Program dates 2019: (Indicate preferences for programs) *
Has this student participated on a REAL program before? *
Are they involved with Laguntas, Next Generation Academy, Lagunta Sisters?
Laguntas *
Next Generation Academy *
Lagunta Sisters *
Boorimul *


PARENT/GUARDIAN DETAILS
Firstname *
Surname *
Address *
City *
State *
Postcode *
Phone 1 *
Phone 2
Email *


Disclaimer: KGI Staff will be in contact with the parent or student prior to the program to provide more details around the program.


EMERGENCY CONTACT DETAILS
Same as Parent/Guardian   


Firstname *
Surname *
Address *
City *
State *
Postcode *
Phone 1 *
Phone 2
Email *


MEDICAL
Medicare Number
Health Care Number
Ambulance Number & Medical Fund
Medical Conditions, Mental Illness, Physical Illness
Name any physical illness or condition (e.g. asthma, epilepsy) for which you are receiving treatment or any medications you are currently taking
Medication while on camp
Tetanus Injection Date
Allergies
Are you allergic to anything, for example Penicillin or other medications, foods, animals or bee stings? If yes, list allergies, how you react and necessary action steps
Do you have any dietary requirements?
If yes please provide details
Are there any other circumstances that may affect your wellbeing whilst on program? This is for us to know how to support you during the week, and everything is confidential.


APPLICANT QUESTIONS


1. How have you displayed leadership qualities and cultural pride in your school and/or community? *
2. How would you rate your school attendance for this year? *
3. What are some future aspirations you have for yourself? *
4. Why do you want to attend this program? *
5. Is there any information that you can provide for us to better understand your needs and capabilities? *


SCHOOL REFERENCE
Please notify your school reference so that they know that you have put them down as a reference on this application.


Firstname *
Surname *
Position *
School *
Phone *
Email *


COMMUNITY REFERENCE
Please notify your community reference so that they know that you have put them down as a reference on this application.


Firstname
Surname
Position
School
Phone
Email


TRANSPORT
Please indicate how the applicant will be travelling to and from the program

To
From






The Korin Gamadji Institute is a part of the Richmond Football Club and is supported by the Australian Federal Government, Culture is Life and the Victorian Electoral Commission.


PRIVACY: All personal information you provide will be used by the Richmond Football Club in accordance with the Club's privacy policy. By providing your personal information, you agree to such use by the Richmond Football Club.


CONSENT: I, the nominator, give consent for the student nominated to attend the Korin Gamadji Institute’s Richmond Emerging Aboriginal Leadership (REAL) program.
   I acknowledge that I have received the information regarding the program and communicated with the student’s parent/guardian.
   I give permission for the KGI to withhold the student’s personal information in line with the Richmond Football Club’s Privacy Agreement and consent to releasing any media involving the student on the REAL program through Richmond Football Club and relevant partners channels.
   As the nominator I also consent to the information provided being as accurate as possible and to being available to receive and respond to any relevant communications regarding the student at the completion of the program. Immediate communications during the program will be made with the KGI staff and the students parents/guardians.
 *