East Gippsland Shire Council Youth Ambassadors Application

1. Your Personal Details

Please ensure all of the details provided are correct

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* 1. What is your name?

First

Last

Preferred

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* 2. How old are you?

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* 3. Preferred Pronouns?

She/Her/Hers

He/Him/His

Them/They

Ze/Hir

Prefer not to say

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* 4. Contact Details

Address

City/Town

Post Code

Country

Email Address

Mobile Number

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* 5. Do you identify as Aboriginal or Torres Strait Islander?

Yes

No

Prefer not to say

33% of survey complete.