headspace Port Lincoln YRG Application Form

headspace Port Lincoln YRG Application Form
YRG Application Form

Thank you for your interest in joining the headspace Port Linclon Youth Reference Group (YRG).

This application will help us get to know you and understand your interest in being part of the team. Please know that the questions about your lived experience are optional and will be treated with respect and confidentiality.

This survey collects your personal details to ensure a streamlined transition if you are accepted into the YRG role. Please note that your data will only be viewed by the YRG recruitment staff at headspace Port Linclon and will not be shared elsewhere. To ensure the privacy of all respondents, the survey responses will be deleted at the conclusion of the recruitment process. However, if you are a successful candidate, your details from this survey will be extracted as a part of the induction process.

Personal Information
Please enter your preferred first name.*

First Name
Please enter given first name (for emergency purposes).

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have any allergies? If so, please list them below.

NoYes
Please list allergies?
Do you have any medical conditions that we should be aware of?
Do you have any dietary requirements? If so, please listthem below.

Parent/Guardian Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
Please enter the first name of your Emergency Contact

First NameLast Name
Please enter the mobile number for your Emergency Contact
Please enter a valid phone number.
Relationship

About You
Tell us a bit about yourself: (i.e., who you are, your interests, anything you'd like us to know)
Why do you want to be involved with the headspace Port Lincoln YRG?
What types of YRG activities would you be most excited to be involved in? (e.g., media, community events, creative projects, consultations, advocacy)
What skills or ideas would you bring to the Youth Reference Group?
Are you involved in any other organisations or community groups? If yes, please list them and briefly describe your involvement. Yes or No

Lived Experience
Please Note: These questions are optional and will be treated with respect and confidentiality.
Do you have experience supporting a family member or friend with a mental health concern?

YesNo
Would you feel comfortable discussing this experience during the recruitment process?

YesNo

Should be Empty: