* 1. Name:

* 2. Phone Number:

* 3. Email Address:

* 4. Address:

* 5. What are the current campaigns or projects you are working on? (150 words max)

* 6. Why are you passionate about creating change? (150 words max)

* 7. What would you like to learn from 'The Change Course'? (150 words Max)

* 8. Outline your previous experience in campaigning and or creating change? (150 words Max)

If you would like to apply for a scholarship or a payment plan please email nicola@counteract.org.au
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