Training Request Form

Name

First NameLast Name
Email*
example@example.com
What is the name of your organisation?*
Where does your outlet (or organisation if there in one site only) operate in Victoria?*

Metro MelbourneBarwonMalleeOvens MurrayCentral HighlandsLoddon Campaspe MalleeWimmera Southern MalleeGreat South CoastGoulburnGippsland
Where is the location where you want The Centre to deliver the training? Please insert name of local area and postcode.*
What aged care service/s does your outlet (or organisation if there is one site only) provide? You can choose more than one option.*

Home CareResidential CareCommonwealth Home Support ProgrammeOther
If you chose other please specify.
Please tell us what issues relating to culturally appropriate care you want The Centre to provide training on? (e.g. list some of the issues you are experiencing)*
How many staff works in your outlet?*
How many staff will participate in The Centre's training?*
What position or roles is the audience you wish us to train (e.g. nurses, personal care workers, case managers)*
What diversity groups does your outlet (or organisation if one site only) service? You can choose more than one option.*

People from Culturally and Linguistically Diverse backgroundAboriginal and Torres Strait Islander PeoplePeople who are homeless or are at risk of becoming homelessPeople who live in Rural, Remote or Very Remote areasPeople with Mental Health Problems and Mental IllnessLGBTIQ PeoplePeople living with cognitive impairment including dementiaPeople with disabilityParents separated from their children by forced adoption or removalCare LeaversVeteransSocio or economic disadvantage
How many seniors does your outlet provide care for?*
Which cultural and language backgrounds do your clients come from who access your services? You can choose more than one option.*

Seniors from Central and Northern European backgroundsSeniors from Western and Southern EuropeanbackgroundsSeniors from Eastern European backgroundsSeniors from Middle Eastern and West Asian backgroundsSeniors from South and South-East Asian backgroundsSeniors from Central and Eastern Asian backgroundsSeniors from Pacific Islander and NZ backgroundsSeniors from Northern African backgroundsSeniors from Southern African backgroundsSeniors from Western AfricanbackgroundsSeniors from East African backgroundsSeniors from Central American backgroundsSeniors from South American backgrounds
What is the approximate number of clients from CALD backgrounds you care for at your outlet/site? *
Would you be open to have this session delivered online?*

YesNo
Do you have a training room available? (face-to-face training only)*

YesNo
How many people fit in the training room?
Will The Centre have access to audio-visual IT equipment for presenting purposes?
Appointment*
Please share with us any other considerations that are relevant for the training.
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