NOMINATION FORM - Richmond Emerging Aboriginal Leadership (REAL) Program


REAL Impact Program
  • Program Dates: April - Sunday 29th - Thursday 2nd

The REAL Impact program is designed for REAL Program alumni and youth over 18 years of age to develop their personal and professional skills to engage and support Indigenous youth.

The program will consist of a weekend intensive from the 29th of March to the 2nd April which will be held at Camp Wyuna in Queenscliff. Following this weekend KGI will host a number of training days that focus on the areas:

  • Physical & mental health
  • Wellbeing
  • Facilitation skills
  • Working with children safety and policies
  • Cultural connection
Dates of training days will be communicated via social media and email.

The REAL Impact program aims to support the development of young Indigenous people into confident and proud community leaders and further assist them in their employment and educational pathways post-secondary school.

Whilst the training days will be open to everyone throughout the year, there will be a limited number of positions for the intensive weekend program. To be eligible for this program please submit the application below, and if you are shortlisted you will be contacted for an interview.
 
APPLICANT'S PERSONAL DETAILS
Firstname *
Surname *
Pronouns *
Address *
Mob/Country/People *
City *
State *
Postcode *
Phone *
Email *

DOB *
Gender *
Year Level *
School *
Region *
Has this student participated on a REAL program before? *
Are they involved with Laguntas, Next Generation Academy, Lagunta Sisters?
Laguntas *
Next Generation Academy *
Lagunta Sisters *
Boorimul *
Other REAL Program *


EMERGENCY CONTACT DETAILS


Firstname *
Surname *
Address *
City *
State *
Postcode *
Phone 1 *
Phone 2
Email *


MEDICAL
Medicare Number
Health Care Number
Ambulance Number & Medical Fund
Medical Conditions, Mental Illness, Physical Illness
Name any physical illness or condition (e.g. asthma, epilepsy) for which you are receiving treatment or any medications you are currently taking
Medication while on camp
Tetanus Injection Date
Allergies
Are you allergic to anything, for example Penicillin or other medications, foods, animals or bee stings? If yes, list allergies, how you react and necessary action steps
Do you have any dietary requirements?
If yes please provide details
Are there any other circumstances that may affect your wellbeing whilst on program? This is for us to know how to support you during the week, and everything is confidential.



APPLICATION QUESTIONS
1. Why do you want to participate on the REAL Impact Program? *
2. How have you demonstrated leadership in your school or community? (List any awards or achievements that you are proud of) *
3. What areas would you like to strengthen or improve in the personal and professional development (What are you hoping to get out of this program)? *
4. What are your ambitions for the future? *
5. What are you passionate about? *


MEDIA CONSENT
I consent to KGI including and/or featuring the Applicant’s name and/or image in the form of a photograph or video in any media releases that the Club may publish (in any medium) from time to time.
 *



CONSENT
I, the Nominator of the Applicant:
 *


PRIVACY COLLECTION STATEMENT:
The Richmond Football Club Ltd (Club / us) is committed to protecting the privacy of the personal information we collect. The Korin Gamadji Institute (KGI) is a division of the Club. We will only use the personal information provided in this nomination form for the purpose of: (1) assessing and processing the Applicant’s nomination for the relevant KGI program; (2) communicating with the Nominator, the Applicant and/or the Applicant’s parent/guardian about the KGI program; (3) contacting the Applicant’s parent/guardian and/or emergency contact during the operation of the KGI program if required (Purposes). If the requested information is not provided in the nomination form, this may prevent us from fulfilling our Purposes.
We may disclose the personal information in the nomination form to others for administrative, educational and health related purposes used in the operation of the KGI program. We may also disclose the Applicant’s personal information to a third party to lessen or prevent a serious threat to the Applicant’ safety or welfare, or when required or authorised by law (such as government departments, agencies). From time to time, we may publish media releases about the KGI program (via various channels including our website, social media platforms) or those of our approved partners which may include or feature the name and/or image of the Applicant. We will otherwise not disclose any of the personal information to any third party without the relevant individual’s consent.
Our privacy policy is available at www.richmondfc.com.au/privacy which contains further details about how an individual can access or correct information we hold about them; how they can make a privacy related complaint; and how that complaint will be dealt with.



The Korin Gamadji Institute is a part of the Richmond Football Club and is supported by the Australian Federal Government, Culture is Life and the Victorian Electoral Commission.