Walking on Yarun - Referral Form

Walking on Yarun - Referral Form

For referring young people to the Walking on Yarun program at Bribie Island. Referrals are currently open for the September session.
Young person's name

First NameLast Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Gender
Address
Type of accommodation
e.g. family, shelter, independent
Has the young person consented to this referral?
Has their parent/guardian consented to this activity?
Does young person identify as:

Other
Contact number for young person and name of contact
Emergency contact details
Is the young person engaged in education and/or employment?
Are there any risks that need to be considered for the young person to participate?
If yes, provide details or YAC will follow up later.
(e.g. AOD, history of violence, peer group)
Does the young person have any disability?
(e.g. health, AOD, disability/physical or MH issue, history of violence, peer group)
Does the young person have any illness/health conditions?
(e.g. health, AOD, disability/physical or MH issue, history of violence, peer group)
How would the young person describe their connection to culture?
How would the young person describe their connection to culture out of 5?
What would the young person like to get out of the program? (Tick all that apply)

Other
What would the young person like to get out of the program?
Referrer's Name

First NameLast Name
Referring organisation or group
Referrer's email
example@example.com
Can the organisation provide transport to and from the program?
Any other comments?
Participant consent
Participant signature
YAC will be in touch to discuss your referral within 72 hours.
Should be Empty:

Walking on Yarun - Referral Form

YAC will be in touch to discuss your referral within 72 hours.