2024 Leadership Excellence Program - Facilitator Applications

Facilitator Application

SLSQ Leadership Excellence Program
Applications Close 8:00am Monday 23rd September 2024.

The program will run from Friday 6th to Sunday 8th December (mandatory leaders day Thursday 5th December) at Saint Leo's College, St Lucia.

Members must attend the entire duration of the program (including leaders' day for facilitators). Days are long and include large portions of time in workshops and presentations.
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Gender*
If Indeterminate- Please specify what pronouns you would like used
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Shirt Size*
What size shirt would you like?
What Branch are you from?*
What Club are you from?*
Occupation*
If you are a Student, what are you studying?
How many years have you been involved in Lifesaving?*
Why did you join Surf Lifesaving?*
Please list any leadership roles you have held in the last 2 years (within & outside of the organisation).*
Have you attended any other State (YEP, LEP, LDP, ALDP) or National (NLC, Masterclass, Women's Mentoring) Program before? If yes, in what capacity (Participant, Leader, Coordinator).*
What is your leadership style and what leadership qualities would you bring to the program?*
Why do you want to be a facilitator and what do you hope to learn from your role on the program?*
Where do you see yourself in the future (both inside and outside of the organisation)?*
What do you consider to be the most important issue in SLS (club, branch state) that needs to be resolved? Please try and be as specific as possible.*
What's one question you would ask the SLSQ CEO, and why?*
What awards do you hold?*

Bronze MedallionIRB CrewmanIRB DriverFirst AidAdvanced Resuscitation Techniques (ART)Silver Medallion Beach Management/Patrol CaptainTrainer/Assessor/Facilitator
Medical Details
Do you have any of the following medical issues:*

NoSkin ConditionsEpilsepsy/Fits/BlackoutsDisability or Chronic IllnessDiagnosed Mental IllnessDiabetesAsthmaAllergiesOther
Please provide further details on medical issue
Do you take any medication?*
Please list these medications and when they are required.
Do you require assistance in taking this medication or is it self managed?
Do you have any Dietary Requirements?*
Please provide further details on dietary requirement
Do you meet SLSQ's Child Protection requirements? (Blue Card, CYRMS & CSA)*
Please provide more information.*
Medicare Number*
Do you have Private Health Insurance? If yes, please provide insurer *
Emergency Contact 1
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship*
Emergency Contact 2
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
MEDICAL DECLARATION: I hereby authorise the obtaining on my behalf of such medical assistance as I may require in the event of accident or illness. I authorise the administering of such medical treatment including the use of anaesthetic, as may be deemed necessary by the Medical Officer attending. I agree to pay the cost of any such medical assistance and any associated costs and expenses and to reimburse Surf Life Saving Queensland Inc. for any such costs and or expenses incurred.
Signature*

Clear
MEDIA AUTHORISATION: I hereby give consent for Surf Life Saving Queensland (ABN 27 360 485 381) ("SLSQ") to use my name, image and/or quote for any SLSQ internal and/or non-commercial external promotion, education or research prposes and that all proprietary rights including intellectual property rights of any image, photograph or likeness of them will be owned by SLSQ.

I agree that my name, image and/or quotes may be used in any medium including, but not limited to provision of footage to the media and on SLSQ social media sites.

I acknowledge that this permission does not extend to the inclusion of my name, image and/or quote in advertising or via paid endorsement without separate approval for this specific purpose.
Clear
FACILITATOR DECLARATION: I hereby declare that the information contained in this application is true and correct to the best of my ability at the date of signing it. I acknowledge that by submitting my nomination to assist in the delivery of this program that I will abide by any requirements of Surf Life Saving Queensland, including all policies, procedures, codes of conduct, etc.

I understand that my responses to all questions will be reviewed as part of the application process.
Signature*

Clear
Should be Empty:

Facilitator Application

Medical Details

Emergency Contact 1

Emergency Contact 2