YOUTH – Life Skills Program – Referral Form Life Skills Program – Referral Form * indicates required field The Life Skills Program provided by the Empower Youth Program and Swan Hill Rural City Council, aims to improve life skills and outcomes for young people who may be at risk of, or are currently disengaged from education or employment, to allow them to live independently. The program will take place one day per week, for two hours over the course of six weeks, and will be located primarily at Youth Inc (50-52 Campbell Street, Swan Hill). It will include a meal each week which participants will cook, as well as discussions around a variety of topics to be chosen by the group. These topics may include, but will not be limited to, financial planning/budgeting, sexual health and relationships, overall health and wellbeing, and local service navigation. How your information will be used The personal, sensitive and health information collected will be used by Swan Hill Rural City Council for the primary purpose of: Ensuring young people are supported during specific program and general service delivery Ensure parents/guardians/ workers and emergency contacts can easily be contacted if required Assist Program workers with strategic program and service planning, delivery and evaluation Create an opportunity to provide you with promotional material about the services and programs Information about your participation in the program and topics arising will also be shared with your nominated person or organisation below. The information you provide shall remain private unless disclosure is required by law, or consented by you.Young person's detailsFull name* Preferred name Mobile* Email* Address* Date of birth* DD slash MM slash YYYY Age* Gender EducationDo you attend secondary school?* Yes No What school do you attend? Highest level of education*--Year 10Year 11Year 12 / equivalentCertificate IIICertificate IVDiplomaBachelor Degree or higherEmployment status*--Unemployed, not looking for workUnemployed, looking for part time/casual workUnemployed, looking for full time workEmployed, Part timeEmployed, CasualEmployed, Full timeVoluntary workCultureLanguage/s spoken* Cultural background* Are you of Aboriginal or Torres Strait Islander descent?* Yes No Do you need an interpreter?* Yes No Living arrangementsWho currently lives your home?*Tick all that apply Just me Mum Dad Siblings Other relatives Friends / roommates Other Other: Health and wellbeingPlease indicate if any of the following applyPlease tick all that apply Disability Asthma Epilepsy Allergies Medications Dietary Requirements Other Please specify any treatment/ medicationIs there anything else we need to know which may affect your ability to participate in a group environment?* Yes No If yes, please provide further information* Do you have a professional person such as a case worker/consultant who has discussed this program with you?* Yes No Would you like this person to attend the Life Skills program with you? Yes No Do you give consent for this professional person to provide further relevant information to the Life Skills Program workers? Yes No If yes, please provide the professional person’s name and organisation Emergency contactRelationship to young person* Full name* Mobile* Home/Business* Address* Person referring Self referral Relationship to young person* Full name* Mobile* Home/Business* Organisation* Applicant conduct agreement Every participant has the right to feel safe when participating in the Life Skills Program. There will be a zero tolerance policy for aggressive behaviour. If you feel that your behaviour at any time may put yourself or others at risk, it is your responsibility to disclose this to program staff prior to commencement. Some topics may deal with sensitive subject matter. If at any time you feel uncomfortable or upset, please let a staff member know or excuse yourself from the discussion. Support will be available on request. Applicant conduct agreement* I have read and understand the above conditions and agree to abide by these conditions Agreement on your responsibilities and information Information and privacy consent* I consent to the collection and use of information and privacy statements as listed above Acknowledgement* I acknowledge that the information collected on this form is true and correct
