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Rekindling the Spirit Burubi program
10-week Men's behavioral change

Start date: Wednesday 02 / 09 / 2026
Finish date: Wednesday 04/ 11 / 2026
Time: 10:00am- 02:00pm
Where: Rock Valley Hall 772 Rock Valley Rd, Rock Valley New South Wales 2480
Some workshops will be conducted on country.
About You
1.Full Name:
2.Date of Birth
3.Address
4.Preferred Method of Contact
5.Enter your preferred method of contact
6.Cultural background:
7.Gender
Emergency Contact
8.Please enter the emergency contact Full name:
9.Relationship to you
10.Please entre the emergency contact person's number
11.Do you require transport?
Consent
I, agree for Rekindling the Spirit to collect the information on this form so they can understand my needs and provide the right support.

I understand that accessing support is my choice and that I can change or withdraw my consent at any time.

I understand that the information I share may be discussed with relevant Rekindling the Spirit staff to help plan and coordinate my support. If there is information I do not want shared, I can let staff know.
12.Please enter your name and the date. This will be used for consent.
Thank you for registering for the Burubi 10-Week program.
A Rekindling the Spirit staff member will contact you.