KGI - On The Road Program Application Form

About the On The Road Program:

The Korin Gamadji Institute (KGI) is delivering its successful REAL Programs and REAL Healthy programs in your community.

Commencing in November, KGI staff will be travelling to a range of communities to provide REAL Program and REAL Healthy Program content and mentoring, and to connect with mob face-to-face. Registration is open to all Aboriginal and Torres Strait Islander young people aged 13-25.

* KGI and the Richmond Football Club are committed to the safety of our people’s health and wellbeing. All staff travelling to these communities will be following strict guidelines and hygienic measures to ensure Government COVID-19 protocols are being met.

PARTICIPANT PERSONAL DETAILS

Firstname *
Surname *
Address *

City *
State *
Postcode *
Phone *
Email *

DOB *
Gender *

PARENT/GUARDIAN DETAILS
(Only required if you are under 18 years of age)
I am currently aged 18 or over

Firstname *
Surname *
Address *

City *
State *
Postcode *
Phone 1 *
Phone 2
Email *

EMERGENCY CONTACT DETAILS
Same as Parent/Guardian

Firstname *
Surname *
Address *

City *
State *
Postcode *
Phone 1 *
Phone 2
Email *

DIETARY REQUIREMENTS

	Do you have any dietary requirements? *

	If yes please provide details

COMMUNITY

	Which region will you be attending? *
	Mildura & Robinvale – 14th/15th November Geelong - 21st/22nd November Shepparton – 28th/29th November Albury & Wodonga – 5th / 6th December Melbourne – Week Commencing 13th December Gippsland January 2021

STUDENT QUESTIONS

	What school do you attend? *


	What is your current year level? *

	Are you enrolled in alternative or higher education programs e.g. TAFE, RISL, University? *

	If yes please provide details

	Are you currently enrolled in any other KGI program? *

	Tee-Shirt Size? *

PARENT/GUARDIAN CONSENT

I give consent for my son/daughter to participate in KGI On the Road Event.

STUDENT CONSENT

I acknowledge that my registration for this program means that I will follow the KGI Code of Conduct:

I will communicate with other students and program staff in a respectful way.
I will listen to, and consider, the views’ of others.
I will report (to KGI staff) any comments or behaviours that make me, or other students, feel unsafe.
I will respect the privacy of others.

PHOTOGRAPH CONSENT

Photographs are often taken during KGI programs and can be used for promotional purposes. By consenting below, you give consent for KGI, the Richmond Football Club and program partners to use any photographs taken on this program for publicity purposes.