Student Application Form

Young Indigenous Leadership Program
Student Application Form
Please complete the form below and return it to Michelle Pipino no later than 19 th November via email. For any
enquiries please call Michelle Pipino on ph: 08 8901 1341 or email: michelle.pipino@fya.org.au
Section 1: Personal contact details
First name: Surname:
Date of birth: Gender: M / F Are you Aboriginal or
Torres Strait islander? Y / N
Current school: Current year level:
School enrolled in for 2013:
Home phone: Mobile:
Residential address:
Postal address:
Name of parent/guardian: Parents contact phone:
Your email: Parents email:
Section 2: “The story of me”: We want to get to know you as a unique individual. Help us to learn who you are by
responding to these questions. Don’t write too much. no more than 50 words per question please.
Family background… (Where did you grow up? Who is your mob (if known)? Who do you live with? Do you have any
brothers and sisters?)
I love to learn about…What subjects are you particularly interested in at school? (e.g. Science. People. Sport. History.)

Young Indigenous Leadership Program
Something i am passionate about is... (e.g. Playing sport? Community issues? Family? Music and dance?)
Describe some of the things that people say you are good at and list some of your achievements:
What are some of the activities that you are involved in outside of school? (Include information about how
long you have been doing these activities for)
What are some special skills that you could share with others in the program? (e.g. I am a confident
speaker. I’ve always been a really organised person. I can pull a rabbit out of a hat!)
When i think about my future i am interested in exploring... (e.g. Job opportunities. Travel. University. Don’t
know.)
I was really proud of myself when... (e.g. Did well at school. Stood up to a bully. Won a sporting achievement)
Why do you want to be in the young indigenous leadership program? (e.g. Meet new people.
Be a role model. Learn how to make a difference.)

Young Indigenous Leadership Program
Section 3 — Additional information:
> Please attach a copy of your latest school report and attendance report.
> Please provide a written reference or recommendation by someone who knows you well to recommend why they
believe you are a good candidate for the IMPACT program. (This could be your principal, year lever coordinator, AIEW,
employer or coach.)
Section 4 — Support person:
Who is a person that can support you through the program? (Could be family member, mentor, school teacher)
Name: ……………………………………………………..
Contact ph: ………………………………………………Contact email: …………………………………………………
Section 5 — Permission:
Please arrange for the following people to sign and confirm their support of your application:
1. Your current school principal
name: …………………………………………………..
signature: …………………………………………………..
date: …………………
2. Your school contact (AIEW, year level
coordinator, teacher)
name: …………………………………………………..
signature: …………………………………………………..
date: …………………
3. Your parent / guardian
name: …………………………………………………..
signature: …………………………………………………..
date: …………………
4. Yourself!
name: …………………………………………………..
signature: …………………………………………………..
date: …………………
Please complete this form and return to Michelle Pipino no later than 19 th November 2012.
Return forms by: Post forms to Michelle Pipino, FYA GPO Box 4385 Darwin NT 0801 Email michelle.pipino@fya.org.au
or Fax Attention Michelle Pipino 8999 3710
For any enquires please call Michelle on 08 8901 1341. You will be notified soon after if you are successful for an interview
with FYA. Please don’t hesitate to contact Program Coordinator, Michelle Pipino if you have any queries. Good Luck!