WB Community Foundation

2022 GOAL Mentoring Program: Participant Nominations

10-session mentoring and development program
Meet new people and build friendships
AFL & AFLW players and community mentors involved in the program
Fun leadership and engaging workshops
13 to 15 year old from African Australian background
LIMITED PLACES AVAILABLE

For more information, please contact foundation@westernbulldogs.com.au

Please answer the questions below as best you can. - Fields with a * are required

First Name *

Last Name *

Email *

Phone Number *

Date of Birth *

Where were you born? *

Where was your mother born? *

Where was your father born? *

Are you of Aboriginal and/or Torres Strait Islander origin? *

The gender I identify with? *

Street Address *

Postcode *

Suburb *

Local Government Area *

School Name *

What year level is the nominated young person? *

If not currently attending school, please describe the activities the nominated young person is undertaking below:

Do you speak a language other than English at home? If so, please tell us which language: *

Do you have any medical conditions and/or allergies that we need to be aware of? If yes, please specify: *

If you take any medication, please tell us below: *

Do you identify as having a disability or require any support? If yes, please specify: *

Do you have any dietary requirements? If yes, please specify: *

Do you have any religious or cultural considerations that we should be aware of? If so, please specify: *

Parent or Guardian Name *

Parent or Guardian Contact number *

Parent or Guardian Email address *

Is an interpreter required to talking to this emergency contact? *

Is your emergency contact the same as the parent/guardian contact listed above? *

If no, please provide the nominated young person’s emergency contact name, number and email below:

Is the nominated young person on NDIS? *

Does the nominated young person have a current casual/part-time job? *

Do you consent for the participant being in photos? *

What is your hoodie size? *

I would like to receive updates about the Western Bulldogs Community Foundation programs and activities.

As the parent, I have read and agree with the GOAL Mentoring terms and conditions , Western Bulldogs Privacy Policy *

Western Bulldogs Community Foundation Terms and Conditions

Before your child starts the GOAL Mentoring program, a parent/legal guardian must read and accept these terms and conditions on their behalf. You need to check the box above to show you understand and agree to these terms and conditions.

This program is run by the Western Bulldogs Community Foundation and partners.

If your child has not exercised for some time or has any health concerns, you should take them to visit a doctor. A doctor will be able to tell you if it is safe for your child to participate in the program. Your child might not be able to participate if they act inappropriately or if participation in the program is unsafe for them.

Your child might be at risk of injuring them self during program activities. You agree not to hold any person or organisation directly or indirectly involved with this program liable for loss relating to any personal injury to the extent permissible at law.

In case of an emergency, you consent to Program staff calling emergency services to take your child to a doctor or hospital for medical help - even if your child does not have ambulance cover. You grant doctors/other professionals permission to give whatever medical or surgical treatment they believe is necessary. You understand you are responsible for paying costs of medical attention, ambulance transportation and treatment if your child hurts them self. We may need to share some of your personal information with these medical professionals.

You must tell us if your child’s emergency contact details change or if their health changes during the program.

If your child needs to take any medication during program hours or camps, you need to tell Program staff before they start in writing in the registration form. If your child needs help taking medication during program hours and camps, all prescribed medication MUST be in a Webster (medication) pack (your chemist can assist you) and must include the name of the medication, dosage instructions and times when the medication is to be administered.

You understand you are responsible for your child’s safety whilst travelling to the program, after program sessions finish and/or whilst they are waiting to be collected from program activities.

Any health information collected by the Western Bulldogs Community Foundation is done so in accordance with the Western Bulldogs’ Privacy Policy, which can be found at www.westernbulldogs.com.au/privacy Information collected will only be used to help your child stay safe at sessions, for program administration; or to contact you/your child during the program or in the future. De-identified information might also be used for program research and evaluation.

You/your child may be sent information updates from the Western Bulldogs Community Foundation or Western Bulldogs Football Club - via email or SMS. These are done so in accordance with the Western Bulldogs’ Privacy Policy. If you/your child do not wish to receive email or SMS communication from the Western Bulldogs Community Foundation or Western Bulldogs Football Club, you can opt out at any time by emailing ‘OPT OUT’ to foundation@westernbulldogs.com.au.

The Western Bulldogs Community Foundation and partnering organisations take photos and video footage during programs, for social media, online and mainstream media use. If you and your child agrees they wish to be featured in photo and video footage, the Western Bulldogs Community Foundation or Western Bulldogs Football Club may use this content for program promotion, to share stories on social channels. We will store the photos safely, without identifying information. If you change your mind at any time we can delete photos. You accept that these photos could be used without being paid. If you do not want your child to be in photos or video footage, they do not have to. Please tell us that you do not consent to this upon registration.

I would like to receive general communications from the Western Bulldogs Football Club, such as match day and membership information.

Allow me to be contacted by sms

Submit

GOAL Mentoring terms and conditions Western Bulldogs Privacy Policy

Western Bulldogs Community Foundation Terms and Conditions

This program is run by the Western Bulldogs Community Foundation and partners.

If your child has not exercised for some time or has any health concerns, you should take them to visit a doctor. A doctor will be able to tell you if it is safe for your child to participate in the program. Your child might not be able to participate if they act inappropriately or if participation in the program is unsafe for them.

Your child might be at risk of injuring them self during program activities. You agree not to hold any person or organisation directly or indirectly involved with this program liable for loss relating to any personal injury to the extent permissible at law.

In case of an emergency, you consent to Program staff calling emergency services to take your child to a doctor or hospital for medical help - even if your child does not have ambulance cover. You grant doctors/other professionals permission to give whatever medical or surgical treatment they believe is necessary. You understand you are responsible for paying costs of medical attention, ambulance transportation and treatment if your child hurts them self. We may need to share some of your personal information with these medical professionals.

You must tell us if your child’s emergency contact details change or if their health changes during the program.

If your child needs to take any medication during program hours or camps, you need to tell Program staff before they start in writing in the registration form. If your child needs help taking medication during program hours and camps, all prescribed medication MUST be in a Webster (medication) pack (your chemist can assist you) and must include the name of the medication, dosage instructions and times when the medication is to be administered.

You understand you are responsible for your child’s safety whilst travelling to the program, after program sessions finish and/or whilst they are waiting to be collected from program activities.

Any health information collected by the Western Bulldogs Community Foundation is done so in accordance with the Western Bulldogs’ Privacy Policy, which can be found at www.westernbulldogs.com.au/privacy Information collected will only be used to help your child stay safe at sessions, for program administration; or to contact you/your child during the program or in the future. De-identified information might also be used for program research and evaluation.

You/your child may be sent information updates from the Western Bulldogs Community Foundation or Western Bulldogs Football Club - via email or SMS. These are done so in accordance with the Western Bulldogs’ Privacy Policy. If you/your child do not wish to receive email or SMS communication from the Western Bulldogs Community Foundation or Western Bulldogs Football Club, you can opt out at any time by emailing ‘OPT OUT’ to foundation@westernbulldogs.com.au.

The Western Bulldogs Community Foundation and partnering organisations take photos and video footage during programs, for social media, online and mainstream media use. If you and your child agrees they wish to be featured in photo and video footage, the Western Bulldogs Community Foundation or Western Bulldogs Football Club may use this content for program promotion, to share stories on social channels. We will store the photos safely, without identifying information. If you change your mind at any time we can delete photos. You accept that these photos could be used without being paid. If you do not want your child to be in photos or video footage, they do not have to. Please tell us that you do not consent to this upon registration.