Application Form Mitchell and Murrindindi Programs, 2017Second Round Applications close Sunday, 9 July 2017. Question Title * 1. Applicant details First name Last name Date of Birth Phone number Email Skype (if available) Address Town/City State Postcode Question Title * 2. Local Government Area you live in(The current program is only open to residents in the Mitchell and Murrindindi Shire area) Mitchell Shire Council Murrindindi Shire Council Question Title * 3. For how many years have you lived in the Mitchell or Murrindindi region 0 100 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 4. Which program are you applying for? Mitchell Program - Social Change 101 Murrindindi Program - Social Change 101 Question Title * 5. Please tell us a little about yourself and what you hope to achieve by attending this workshop (max 200 words) Question Title * 6. How will your venture benefit the community in the Mitchell and/or Murrindindi region? Question Title * 7. What is the name of your social venture? (It’s ok if this changes) Question Title * 8. Tell us about your idea and the impact it will have (max 200 words) Question Title * 9. What is the problem your idea is working to solve or avoid? Question Title * 10. Will your idea have a direct community benefit in the Mitchell and/or Murrindindi region? Yes No PROGRAM EXPECTATIONSIf you are selected into the Social Change 101 program, you will be expected to commit to:- Attending all program sessions- Completing all projects and learning tasks- Meeting and working with your mentor Question Title * 11. I understand the program expectations of the Social Change 101 program Yes No Question Title * 12. I give permission for my photo to be used in future publicity and official publications that may result from this program Yes No FURTHER INFO Question Title * 13. How did you hear about the Social Change 101 program? Facebook Newspaper Email Friends, family, colleagues Website Other (please specify) Question Title * 14. Much of our communication will be via email. Does this create any problems / difficulties for you? Yes - I have trouble/issues with email No - email is fine Submit Application