NOMINATION FORM - Richmond Emerging Aboriginal Leadership (REAL) Program
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KGI REAL Determined Program Dates
  • April 2019:   Sunday 7th - Friday 12th
  • July 2019:   *NAIDOC Program in Melbourne* Monday 8th - Friday 12th
  • 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 *
Address *
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


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 *