MASTERCLASS FOR YOUNG PEOPLE LIFE SKILLS PROGRAM
  • Home
  • About
  • Contact
  • Train The Trainers Project
  • Application Form
  • Blog
  • Events



   

Application Form

 

PERSONAL DETAILS  

All personal information provided will be handled confidentially in accordance with the Privacy Act

 

Surname:  ____________________Child’s Name/s:  _______________________________________

 

Address:  _________________________________________________________________________

 

Date of Birth:______/______/______  M/F _____   Medicare No. __ __ __ __   __ __ __ __ __   __

 

                                                                             Line No. __

 

ISSUES:  □ Anger            □  Depression        □  Self Esteem        □  Communication       

 

Other: ____________________________________________________________________

_________________________________________________________________________

 

PARENT/GUARDIAN’S DETAILS:

 

Surname  ______________________________Name:  ____________________________________

 

Address:__________________________________________________________________________

 

Contact Number::  Home:  _________________Mobile______________Email:  ________________

 

Emergency Contact Person: ___________________________________________________________

 

Emergency Contact Number:__________________________________________________________

 

PAYMENT OPTIONS

Direct Debit: CBA – BSB 063 530

Account No. 10481438

Vicki Omifolaji Consulting

Please quote name and notify by either text or email

Or

 

Major Credit Cards

Details

□ Mastercard □ Visa □

Card No. __ __ __ __/__ __ __ ___/__ __ __ ___/__ __ __ __

Expiry ____/____  Amount: $_____________________

Signature:  _____________________________________

 

 

I acknowledge that this Life Skills Program application does not automatically guarantee me a position in the delivery pathway of the program.

 

I understand and acknowledge that I am responsible for any fees and meeting timeline requirements.

 

_________________________________                                           ___________________________

Parent/Guardian’s Signature                                                     Date

Powered by Create your own unique website with customizable templates.
  • Home
  • About
  • Contact
  • Train The Trainers Project
  • Application Form
  • Blog
  • Events