Program Intake Form

Representative Details:

First Name

Last Name

Contact Number:

Email Address

Comments

Which program are you interested in?

Before submitting your enrolment, please check our website for detailed information on our program eligibility, session times, and fees.

Programs: *

Boys to Leaders Boxing Program (Males)Empower Her Boxing Program (Females)Inclusive Boxing Program (Boys & Girls) Fishing Day Out (Girls & Boys)Young Achievers Program (Boys & Girls)

Comment:

In-School Mentoring Sessions:

YesNo Unsure

If unsure please provide details.

Details:

Which workshop are you interested in?

Before submitting your enrolment, please check our website for detailed information on our workshops eligibility, session times, and fees.

Workshops:

Barber Workshop (Boys)Expressive Writing Workshop (Girls & Boys)All About Me Workshop (Girls & Boys)Resume Workshop (Girls & Boys)Apply for Jobs Workshop (Girls & Boys)

Questions:

Details of the young person you're enrolling for:

This section is only if you're enrolling an individual young person

Client First Name:

Client Surname:

Client Contact Number:

Client Email Address:

Date of Birth: *

Client Address:

Client Gender: *

Male FemaleIntersex

Client's Preferred Communication Method:

PhoneText (SMS)EmailMail

Client NDIS Number:

Details of the Organisation you're signing up for:

Name of Organisation: *Provide details of the Organisation you represent (e.g. OOHC, Youth Services, School, Community-Based Services, etc).

Where can Young Leaders Youth Services operate or run these programs?Example: If a school is enrolling, is there access to an area such as a hall, open field, or playground to run the programs? If you're an organisation, is there a specific location available to facilitate the programs (e.g., an office space, outdoor area, or a chosen venue) or is there another preferred location (PCYC, Hall, Community Centre)?

If no, do you require Young Leaders Youth Services to provide a venue?

Yes No

Number of Participants: *

Age Group Of Participants: *

Please provide any relevant details about the participants, goals, or specific needs:

Representative or Emergency Contact Details:

Emergency Contact First Name: *

Emergency Contact Surname: *

Emergency Contact Primary Number: *

Relationship to Client: *

To be signed by the authorised Representative:

Name:

Date:

Representative Signature *

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