NOMINATION FORM - Richmond Emerging Aboriginal Leadership (REAL) Program


KGI REAL Determined Program Dates
  • September 2019:   Sunday 22nd - Thursday 26th
  • April 2020:   (dates to be confirmed)
  • September 2020:   (dates to be confirmed)

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
 
APPLICANT'S 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 - NOMINATOR
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




MEDIA CONSENT
I consent to KGI including and/or featuring the Applicant’s name and/or image in the form of a photograph or video in any media releases that the Club may publish (in any medium) from time to time.
 *



CONSENT
I, the Nominator of the Applicant:
 *


PRIVACY COLLECTION STATEMENT:
The Richmond Football Club Ltd (Club / us) is committed to protecting the privacy of the personal information we collect. The Korin Gamadji Institute (KGI) is a division of the Club. We will only use the personal information provided in this nomination form for the purpose of: (1) assessing and processing the Applicant’s nomination for the relevant KGI program; (2) communicating with the Nominator, the Applicant and/or the Applicant’s parent/guardian about the KGI program; (3) contacting the Applicant’s parent/guardian and/or emergency contact during the operation of the KGI program if required (Purposes). If the requested information is not provided in the nomination form, this may prevent us from fulfilling our Purposes.
We may disclose the personal information in the nomination form to others for administrative, educational and health related purposes used in the operation of the KGI program. We may also disclose the Applicant’s personal information to a third party to lessen or prevent a serious threat to the Applicant’ safety or welfare, or when required or authorised by law (such as government departments, agencies). From time to time, we may publish media releases about the KGI program (via various channels including our website, social media platforms) or those of our approved partners which may include or feature the name and/or image of the Applicant. We will otherwise not disclose any of the personal information to any third party without the relevant individual’s consent.
Our privacy policy is available at www.richmondfc.com.au/privacy which contains further details about how an individual can access or correct information we hold about them; how they can make a privacy related complaint; and how that complaint will be dealt with.



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.