NOMINATION FORM - Richmond Emerging Aboriginal Leadership (REAL) Program
online or printable is accepted   Print PDF


* Please note April and July 2019 program dates to be confirmed
  • September 2018: Sunday 23rd – Wednesday 26th
  • April 2019: dates to be confirmed
  • July 2019: dates to be confirmed

Thank you for nominating your student for the The Korin Gamadji Institute’s ‘Richmond Emerging Aboriginal Leadership Program’. The REAL Program is a four-day intensive focusing on connecting Indigenous youth from across the state to culture and each other. Accommodation and catering will be provided by KGI.

Teachers or support workers can now nominate eligible students who fit the criteria below
  • Identified as Aboriginal or Torres Strait Islander
  • Currently enrolled in year 9 or 10
  • Display commitment or willingness to learn and be active in the community
  • Reputable attendance and behavioural record

Information gathered in this Nomination Form will be used solely to aid agencies involved with the program and to provide participants with the best possible support.

Nominations must be received a minimum two weeks prior to the commencement of the program.

If the nomination form has not been received by the cut-off date, we will offer your place to someone else as we are restricted to 30 participants for all programs. Please make sure all sections of this form are filled out as the student will not be considered if all details are not completed. It is important that we have this information for effective and safe delivery of the program.

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 *
Address *
City *
State *
Postcode *
Phone *
Email *

DOB *
Gender *
Year Level *
School *
Region *
Program dates 2018: (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


STUDENT REFERENCE
In what ways has this young person shown their leadership qualities within your school and/or community?


1. How has the student nominated displayed leadership qualities and cultural pride in their school and/or community? *
2. How would you rate the student's school attendance for this year? *
3. What are the student's education, career aspirations or subject interests? *
4. Is there any information that you can provide for us to better understand the needs and capabilities of the student? Eg. Attitudes, behaviours? *


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

To
From


PERSON NOMINATING STUDENT
I hereby state that the information listed in this registration form is true and correct.


Firstname *
Surname *
Position *
Phone *
Email *

I the nominator, have communicated with the student’s parent/guardian and they give consent for their child to attend the REAL Determined Program. *




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.


As the person nominating I understand it is my responsibility to complete the application form accurately and timely and provide relevant support to the student/s I am nominating before and after the program. I am also agreeing to provide feedback through an online survey *