Participant Application Form

All application forms to be posted, faxed or emailed to: St Vincent de Paul Society, 2010 Immersion Program, PO Box 1468, Nightcliff, NT 0814

Fax: 08 8948 2844 Email: youth@svdpnt.org.au By Monday 11th January 2010

Please complete this entire form to register your interest in participating in the 2010 Immersion Program. All of the information provided by you will remain strictly confidential and will not be

passed on by the St Vincent de Paul Society to anyone unless specified by you.

Surname: __________________________ Given Names: _________________________

Date of Birth: _ _ / _ _ / _ _ _ _ Gender: Female / Male State / Territory: ________

Postal address: _____________________________ Suburb: _______________________

Post code: ___________ Email: ______________________________________________

Mobile: ______________ Home No: ________________ Work No: _________________

How would you prefer us to contact you? ________________________________________

Hobbies / Interests: __________________________________________________________

Are you currently a member or volunteer with the St Vincent de Paul Society? Yes / No

If yes, when did you start? ____________________________________________________

What Vincentian conference(s) and/or work(s) are you involved in? ____________________

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Why are you involved with the St Vincent de Paul Society? ___________________________

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Why would you like to take part in the Immersion Program? __________________________

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What do you hope to get out of this Immersion Program? ____________________________

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St Vincent De Paul Society Immersion Program

2006

This is a spiritual program as much as it is a practical program and you will be expected to reflect on your experiences throughout the time. How does this sit with you?

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What other skills do you have that may be useful? __________________________________

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Describe your previous experience with young children. _____________________________

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Describe your previous experience working in a team environment. ____________________

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Have you ever visited an indigenous community before? If so, please give details. ________

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What activity do you think you could run in the Indigenous Community? _________________

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How did you hear about the Immersion Program? __________________________________

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Is there anything else you would like to add that you haven’t covered in a previous question?

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Details of a referee who knows you from your involvement with the St Vincent de Paul Society (not a family member):

Name: ________________________ Role in Vinnies: _____________________________

Contact phone numbers: ______________________________________________________

We may also contact your relevant St Vincent de Paul Society State or Regional office to ask for a reference.