headspace Ashfield Youth Reference Group (YRG) Application
Legal name
First Name
Last Name
Preferred name
First Name
Last Name
Phone number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth
DD/MM/YYYY
Gender assigned at birth
Current gender identity and preferred pronouns
What languages do you speak at home?
Where were you born?
Are you Aboriginal or Torres Strait Islander?
Are you from a rural or remote area?
Do you have a family member with a mental illness?
Do you identify as having/had a mental illness?
Is this something that you would be happy (and feel comfortable) talking about?
About You
Please tell us a bit about yourself?
(For example: I am 15 years old, and attend alternative education centre 3 days a week, I like skate-boarding etc)
Please describe why you are interested in becoming a Youth Reference Group member?
What skills and ideas could you bring to the Youth Reference Group?
Are you involved in any other organisations? If yes, which ones and what is your involvement?
Submit
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