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
