Community Group Request Form

Group Details

Are you from an organisation based in Australia?*

YesNo

Name of Community Group*

Location*

—Please choose an option—MelbourneGeelongNSWTasmaniaOther

Preference for Facilitator Gender*

—Please choose an option—Either Male or Female or BothFemaleMale

Number of People In Community Group (eg. 20)*

What is the Gender Split of the Group?*

—Please choose an option—100% Male75% Male / 25% Female50% Male / 50% Female25% Male / 75% Female100% Female

What is the Venue Address where the Session would take place?*

Do you have any preferred Meeting Dates and Times?*

eg. Sunday 19th June, 11am

Is an Interpreter Required?*

—Please choose an option—YesNoPreferred, But Not Essential

Are there any specific Topics of Interest (eg. Diabetes)?*

Your Details

Your Name*

Your Organisation*

Your Email*

Your Phone Number*

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