headspace Mount Gambier Youth Reference Group Application
Thank you for applying to join the Youth Reference Group!
Our YRG provide an important insight into their lived experiences of being a young person in Mount Gambier and the Limestone Coast and help inform our service delivery. We are looking forward to having you be a part of the group :)
Your details
Name
*
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (00) 00-000-000.
Address
Street Address
Town/Suburb
Post Code
Email
example@example.com
Emergency Contact information
Please note that if you are aged under 16 years of age, we require parental/guardian consent for you to join the YRG.
Name
First Name
Last Name
Relationship to applicant
Phone Number
Please enter a valid phone number.
Format: (00) 00-000-000.
Cultural background
What country were you born in?
What languages do you speak at home?
Do you identify as Aboriginal & or Torres Strait Islander
Please Select
Aboriginal
Torres Strait Islander
Aboriginal & Torres Strait Islander
No
Are you culturally or linguistically diverse?
Yes
No
About you
Do you or a family member have experience with mental illness?
Yes
No
Is this something you are comfortable to talk about?
Yes
No
Please indicate if you have lived experience or passion in any of the following areas
Mental health
Physical health
Sexual health
Alcohol & other drugs
LGBTIQA+
Homelessness
Culturally & Linguistically Diverse
Aboriginal & Torres Strait Islander
Other
Please tell us a bit about yourself...
Do you have any previous experience in committees or volunteering?
Thank you for completing the YRG application
We will get in contact with you in the coming weeks to arrange an interview with you.
Submit
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