LGBTQIA+ Peer Steering Committee Application

Headspace Northam's LGBTQIA+SB Peer Steering Committee Application
Imagine a super chill, welcoming space with games, creative vibes, and seriously good food—somewhere you can hang out with people who get you. Sounds pretty great, right? Well… good news! Headspace Northam is building an LGBTQIA+SB drop-in space for 2026, and we want YOU to help create it!

We’re looking for young people aged 16–25 from the LGBTQIA+SB community in Northam and the wider Wheatbelt to join our very first Peer Steering Committee. As part of the crew, you’ll help co-design the space—from the look and feel, to the values, activities, catering, and all the fun stuff that makes it yours. This is a paid opportunity, and we’d love to hear from you!

Submit your application form, and if you’re shortlisted, we’ll get in touch for a chat. If you’ve got questions or want to talk it through, contact Nina at ce@headspacenortham.com.au or call 08 9621 5000. 🌈✨
Full Name*

First NameLast Name
Chosen/Preferred Name*
Pronouns*
Date of Birth*

MonthDayYear
Phone Number*
Email*
example@example.com
Suburb of Residence*
About You
To help us learn a bit more about you, please share some information about your hobbies, ambitions, passions and interests.*
Why are you interested in joining the Peer Steering Committee?*
Accessibility
Is there anything we should know that might affect your engagement in the Peer Steering Committee?
Do you have any accessibility requirements? (If yes, provide more information)
Do you have any allergies or medical conditions we should be aware of? (If yes, provide more information)
Commitment and Availability
The Peer Steering Committee will consist of at least 2 x two-hour-long meetings (likely to be hosted on a Wednesday afternoon - outside of school hours); however, there may be more as the drop-in space grows. Are you able to commit to this level of involvement?*
Do you foresee any barriers or challenges to participating fully in the Peer Steering Committee, and how can we support you?
Emergency Contact Details

Please provide details for at least one emergency contact.
Emergency Contact #1*

First NameLast Name
Relationship to you*
Example: Mother, Father, Guardian
Phone Number*
Email*
example@example.com
Emergency Contact #2

First NameLast Name
Relationship
Example: Mother, Father, Guardian
Phone Number
Email
example@example.com
Should be Empty:

Headspace Northam's LGBTQIA+SB Peer Steering Committee Application

About You

Accessibility

Commitment and Availability

Emergency Contact Details