Banksia Gardens Ambassadors Project - Expression of Interest form -

FOR PARENTS/CARERS OF A PERSON WITH A DISABILITY

Thank you for your interest in becoming an Ambassador! Ambassadors will be sharing personal stories of transitioning into work, study, training, volunteering or community participation. We aim to inspire and inform audiences with personal presentations and with information gathered from the Ambassadors' experiences. Please take time to complete this Expression of Interest form by July 12th 2013. You are always welcome to contact Rachel or Tash for any help or to arrange a meeting at Banksia Gardens to apply Call: 03 9309 8531 or Email: rachel.w@banksiagardens.org.au

Name Age.. Address. Phone. Email

1. What is your relationship to the person with a disability?

What is their name? Age?

2. Is the person you care for Employed? Studying? (Please circle)

Volunteering?

3. Where is the person you care for employed/studying/volunteering?

4. How long has the person you care for been employed/studying/volunteering?

5. Has work/study/volunteering been a positive experience for the person you care for? If yes, why? If not, why?

6. Why are you interested in becoming an Ambassador?

7. Have you ever had any public speaking experience?

8. Will you be comfortable (happy) to present your personal story to an audience and on video?

9. What activities, people or experiences have helped the person you care for on their journey to work/study/volunteering?

10. Has or is the person you care for registered with a job agency? (If so, which one?)

11. Are you able to commit to a weekly workshop (on a weekday or week night) for 6 weeks in either July/August (Round 1) or September/October (Round 2)?

Please indicate which training round you prefer: Round 1(July/August) - held in Hume Round 2 (September/October) - held in Moreland Either

12. Where did you hear about the Ambassadors program?

13. Will you require any specific assistance or facility for the Ambassadors training?

Thank you for taking the time to complete this form!

Please do one of the following: - Scan and email this form to: rachel.w@banksiagardens.org.au - Post or drop this form in at reception to: Rachel Wood, Banksia Gardens Community Services, 71 81 Pearcedale Parade, Broadmeadows - If you would like assistance completing this form, please call 03 9309 8531 to see Rachel or Tash at Banksia Gardens Community Services