Empowering YOUTH Program - NT Lived Experience Network

Empowering YOUTH Program - Registration Form

Participant Name *

Please provide the full name of the participant.

Participant Age *

Please provide the age of the participant.

Caregiver Name *

Please provide the full name of an authorized care giver.

Caregiver Phone Number *

Please enter a contact phone number for the caregiver.

Caregiver Email *

Confirm Email

Please enter an email for the caregiver.

Caregiver Address *

Please provide an address for the caregiver.

Please select which program you interested to attend. *

Katherine Program (9 am to 12 pm on Mon 27 June, Tue 28 June, Wed 29 June and Thu 30 June)
Alice Springs Program (9 am to 12 pm on Tue 12 Jul, Wed 13 Jul, Thu 14 Jul and Fri 15 Jul)

Please confirm the you plan to participate in all four sessions of the program: *

I agree

Please confirm that we can contact the participant and/or their authorized caregiver to discuss ways about ways to support their participation in the program: *

I agree

Please confirm that both the participant and their authorized care giver agree to this registration: *

Participant agrees
Caregiver agrees

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