Rekindling Registration 2019 To be completed by applicant. Question Title * 1. I would like to register for the Rekindling Program in: Northern Peninsula Area (NPA) QLD Rockhampton QLD Cherbourg QLD Matraville/La Perouse NSW Question Title * 2. About You First Name Last Name What school do you attend? Question Title * 3. Date of Birth Please complete in the format DD/MM/YYYY Date Question Title * 4. Gender Male Female Other Question Title * 5. Home Address Street Address Suburb Post Code Question Title * 6. I am: Aboriginal Torres Strait Islander South Sea Islander Other (please specify) Question Title * 7. Please specify the name of your Aboriginal and/or Torres Strait Islander language group(s) (if known). Question Title * 8. Do you have any pre-existing injuries, health problems, or learning disabilities? No Yes (please specify) Question Title * 9. What is your t-shirt size? Extra Small Small Medium Large Extra Large Question Title * 10. Please upload a photo of your face so that we know who you are! Photo of just yourself, head and shoulders visible. DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File Photo of just yourself, head and shoulders visible. To be completed by a parent/guardian. Question Title * 11. Parent/Guardian Details First Name Last Name Email Address Phone Number Question Title * 12. Would you like to subscribe to Songlines newsletter? Yes No Question Title * 13. In the interest of confidentiality, media and photography, please indicate if your child is: A ward of the state Living in foster care None of the above Question Title * 14. Please confirm you have read and agree to the terms outlined in the Permission & Disclaimer Form. Yes Collection NoticeThe information you provide in this form is personal and sensitive. This form allows us to make an assessment, and provide you with access to our Rekindling Youth Program. We respect your privacy and will treat the information you provide to us with utmost confidence. In order to provide our Rekindling Youth Program, we may be required to share necessary personal information with relevant venues, or adults involved in the program. We collect, use, disclose and store your personal and other information in accordance with our privacy policy, which you can view here. Bangarra Dance Theatre02 9251 5333bangarra@bangarra.com.au Done