2027 Break Through Coordinator Applications

2027 Break Through Program Coordinator Application

18th - 20th of January 2027
APPLICATIONS CLOSE ON FRIDAY 03/JULY/2026 @ MIDNIGHT
Program Details
- Tyalgum Ridge Retreat, 18–20 January 2027
- Full attendance for the entire duration is mandatory
Role
- Assist in planning and delivery of the program
- Support leaders on camp to build confidence, leadership, and lifesaving skills
- Attend planning meetings (via Teams and in person)
- Attend in-person onboarding night — 27 July 2026
Eligibility
- Aged 18+ at the time of the camp
- Current financial member of an SLSQ affiliated club
- Hold a valid Working with Children Blue Card or Exemption Notice
- Have participated as a leader at a Branch or State Development Camp
- Completed the Child Youth Risk Management Strategy (CYRMS) Induction
- Club endorsements required for all applications
FURTHER INFORMATION CAN BE FOUND IN THE CIRCULAR
Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Blue Card Number
Blue Card Expiry Date

MonthDayYear
Date
Name on Card

First NameLast Name
Gender
If Non-binary: Please specify what pronouns you would like used
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Branch
South Coast Clubs
Point Danger Clubs
Shirt Size
Please Note Size
What Programs/ Event have you been a part of a leadership team have you held a leadership role before club/branch/state or outside of lifesaving.
Why would you like to be a coordinator on this program?
What Experience will you bring to the Coordination Team?
Can you commit to assisting at every stage of this program? (pre, during and post) this will be done through individual tasks and group planning sessions on Microsoft Teams and in person
Medical Details
Do you have any of the following medical concerns:

Other
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
Emergency Contact 1
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
Emergency Contact 2
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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
Date

DayMonthYear
Date
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.
Particicpant Signature
Date

DayMonthYear
Date
COORDINATORS 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 participate in this program that I will abide by any requirements of Surf Life Saving Queensland, including all policies, procedures, codes of conduct, etc.

I will also make sure i adhered to the SLSQ Policy MS02 - Chaperoning & Supervision of Minors Policy and also the SLSQ COde of Conduct

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

DayMonthYear
Date
Should be Empty:

2027 Break Through Program Coordinator Application

APPLICATIONS CLOSE ON FRIDAY 03/JULY/2026 @ MIDNIGHT

Medical Details

Emergency Contact 1

Emergency Contact 2