Amplify Myrtleford CLP Online Application Form

2025 Amplify Myrtleford Community Leadership Program

Confidential Application

This program aims to empower Myrtleford community members to learn how to think differently; not only to tackle challenges of any scale and size, but to create transformative change in their own lives, and in reshaping the future of our thriving and vibrant region.

Please note: This program accepts applications from individuals living in or with a connection to the Myrtleford community & surrounds.

Personal Information

Name*

First Last

Preferred Name

Date of Birth*

Preferred Pronouns*

* Gender pronouns are the terms people choose to refer to themselves that reflect their gender identity. These might be he/him, she/her or gender-neutral pronouns such as they/them.

Home Address*

Street Address Address Line 2 City State Postal Code

Home Phone*

Mobile Phone*

Email*

Spoken Languages*

Emergency Contact Name and Relationship*

Emergency Contact Phone Number*

Do you identify as Aboriginal or Torres Strait Islander?*

Yes
No

Do you identify as a person with a disability?*

Yes
No

Do you identify as a recent migrant?*

Yes
No

AVCL endorses equal opportunity in program participation; we provide the same benefits and opportunities to all applicants, without discriminating due to protected characteristics such as age, gender, sexual orientation, ethnicity, nationality, religion, disability, and medical history. AVCL aims to promote participation in the program on an equitable basis, and will accommodate any participants as necessary to ensure their inclusion in the program. We encourage applications from first nations peoples, those who are CALD, living with a disability, or of any other minority group.

1. What do you hope to gain from the program?*

2. What are your key areas of focus for the future of Myrtleford and surrounds?*

3. What is your tie to Myrtleford and surrounds?*

4. Do you have any medical conditions, concerns, and/or needs including accessibility needs?

5. Do you have any dietary requirements? If yes, please specify

How did you hear about the Amplify Myrtleford Community Leadership program?*

Applicant Commitment*

I understand the time commitment of the program.
If selected, I will attend all program sessions (please include information in this application if you are aware that you will not be able to attend all days.)
I agree to complete the required pre-program and post-program surveys
I will come with a respect for all my fellow participants and contribute to making a safe and inclusive learning environment.
I give permission to be photographed and for photos to be used for media and promotional activities, including but not limited to by AVCL, Regional Development Victoria & Alpine Shire Council.

Applicant Signature*

Date*

2025 Amplify Myrtleford CLP Online Application Form

2025 Amplify Myrtleford Community Leadership Program

Confidential Application

Personal Information