Diversity Group Registration Form

Diversity Group Registration Form
Welcome to the headspace Bendigo Diversity Group. Please complete the registration form that will assist us to gather important information about you, and to ensure you are well supported during the group. The diversity worker will discuss privacy and confidentiality with you as part of the registration process, including how your information will be used.

Due to COVID19, physical distancing restrictions and guidelines set out by the Department of Health and Human Services, we are no longer able to have face to face Diversity Groups. Our groups are now meeting online using the platform, Microsoft Teams.

Upon receiving the completed registration form, the diversity worker will send you a calendar invite for the diversity group which coincides with your age group.
Name: *

First Name Last Name
Date of birth: *

Day Month Year
Date
Gender identity: *
Sex assigned at birth: *
Do you identify as LGBTIQA+ and/or Ally? *
Pronoun/s: *

She/Her/Hers He/Him/His They/Them/Theirs Use only my first name or nickname I alternate between pronouns
Mobile: *
Other phone: *
Email: *
Address: *

Street Address

Street Address Line 2

City State

Post Code

Emergency Contacts
Please provide contact person/s in case of an emergency, including any information you would not want us to disclose to an emergency contact.

(e.g. sexuality, gender identity, pronouns).
Person 1
Name: *
Phone: *
Relationship to you: *
Knows you as (name, gender, etc): *
Person 2
Name: *
Phone: *
Relationship to you: *
Knows you as (name, gender, etc): *
PLEASE NOTE: If your family are not aware of you attending Diversity Groups or of your identity, please let the Diversity Worker know.

Diversity Group Code of Conduct
Welcome to Diversity Group 😊

Being a headspace Bendigo Diversity Group member is a great opportunity to promote the positive image of young LGBTIQA+ people as well as mental health. Your behaviour as a member of Diversity Group should enhance the reputation of headspace Bendigo and what it stands for, as well as being considerate of other members’ needs.

Group Logistics

Diversity Group is headspace Bendigo’s social support group for young same-gender attracted, sex and gender diverse (SGASGD) youth and is made up of young people aged 12-25.

Diversity Group hopes to:
1. Provide you with a safe space to be yourself.
2. Provide opportunities for you to share and learn information relating to SGASGD young people.
3. Provide a place for you to meet and form friendships with other young people who are going through a similar experience to you.
4. Allow you to participate in local LGBTIQA+ related activities and events.
5. Encourage you to be involved in planning and organising LGBTIQA+ activities and events to be facilitated by headspace Bendigo.
Participation Requirements

headspace Bendigo recognises that individuals have different commitments outside of Diversity Group leading to different individual time and availability, therefore your attendance does not have to be consistent. You will not lose your place within the group if you miss any number of meetings.

Note: You are only to attend the group that is for your age.

Diversity Group meetings are held online using the platform Microsoft Teams.

FROGS – Full Range Of Gender and Sexuality, Wednesdays from 4:00-6:00pm 18-25 years of age.

TADPOLES – Trans And Diverse People Openly Loving Everyones Sexuality, Thursdays from 4:00pm – 5:30pm 12-17 years of age.

Diversity Group Rules
- Be inclusive and respectful of others – no name-calling or discriminatory language.
- There is no pressure to share any personal information you do not feel comfortable with.
- Don’t be afraid to ask questions – there is no dumb question!
- Everything spoken about during meetings should remain private and confidential – do not use any group members name or other personal details when talking or sharing stories outside of the group.
- Listen to others when they are speaking, you have two ears and one mouth use them equally.
- Don’t make any assumptions about group members.
- Ask to talk to the group facilitator one-on-one if there is something you want to discuss privately.
- The group facilitator’s work mobile is only accessed Tuesday-Friday, 9am-5pm. The mobile is used to contact Diversity Group members about meetings and activities. Only contact the facilitators work mobile in response to the facilitator or for matters relating to Diversity Group. The mobile is not to be contacted in emergency or crisis situations (see below for these contact numbers).
PLEASE NOTE: Noise is always to be ekpt to a minimum whilst in the headspace building and online. Please be respectful of others who have sensory issues.

Problem Solving & Dispute Resolution

Any complaint, unresolved problem or serious dispute that involves Diversity Group members is to be brought to the Diversity Group facilitator for resolution. If appropriate, and with the agreement of all parties, the matter may involve a mediation process. A range of mediation options will be made available.

headspace Bendigo reserves the right to exclude any young person if headspace Bendigo believes the young person has acted inappropriately (this may include violence/fighting, verbal abuse, bringing down the name of the group or headspace Bendigo, causing other group members to feel distressed, etc.). If such steps are taken, the member’s participation with Diversity Group will be reassessed with their consultation and may mean a predetermined timeframe of exclusion from the group or immediate expulsion.

Care and Support for Diversity Group Members

headspace Bendigo promotes early intervention and help-seeking for mental health and drug and alcohol issues. It is therefore expected, that as a representative of headspace Bendigo, you acknowledge this and you yourself seek appropriate supports when required. Therefore, if at any time you feel you need to take a break, seek help or support then headspace Bendigo will respect this.

It is important if you (or another group member) are feeling mentally unwell or are in a crisis situation and believe that you are at risk to yourself or others, that you contact a trusted adult or an appropriate support service to get the right help. These services and their contact details are listed below:

Regional Triage/Psychiatric Services (24/7) – 1300 363 788

Police or Ambulance (24/7 and complete welfare checks or transport to hospital) – 000

Lifeline (24/7) – lifeline.org.au or 13 11 14

Kids Helpline (24/7) – kidshelp.org.au or 1800 55 1800

eheadspace (7 days, 9am-1am) – eheadspace.org.au or 1800 650 890

Qheadspace - online

headspace Bendigo – 5406 1400

I have read the information contained in this document and agree to abide by the Diversity Group Code of Conduct.
Full name: *

First Name Last Name
Signature: *

Clear
Date: *

Day Month Year
Date
If you are under 16 years of age, and it is safe for you to do so, please have the following section completed and signed by a parent or guardian and return to the Diversity Group facilitator.
I First Name Last Name of Street Address City State Postcode give my permission for First Name Last Name to participate in the headspace Bendigo Diversity Group.
Signature:

Clear
Date:

Day Month Year
Date
Should be Empty:

Diversity Group Registration Form

About you

Emergency Contacts

Diversity Group Code of Conduct