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BYA Contact Information Form
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* Indicates required question
Full name:
*
Your answer
I am know as:
*
Your answer
Pronouns:
Your answer
Is this name safe in every setting?
YES
NO
Clear selection
If NO, please specify:
Your answer
Address:
*
Your answer
Phone number:
*
Your answer
Email:
*
Your answer
Date of birth:
*
MM
/
DD
/
YYYY
Emergency contact name:
*
Your answer
Relationship to you:
*
Your answer
Phone number:
*
Your answer
Email:
*
Your answer
Do you speak a language other than English at home?
*
Your answer
Are you of Aboriginal or Torres Strait Islander origin?
*
YES
NO
Do you identify as LGBTQIA+?
*
YES
NO
Prefer not to say
Who do you live with?
*
Your answer
Do you use any medication?
*
YES
NO
If yes, what for?
Your answer
Are you on Centrelink benefits?
*
YES
NO
UNSURE
Are you working?
*
Casual
Part time
Full time
No
Are you studying?
*
YES
NO
If yes, where are you studying?
Your answer
Do you have a driver's licence?
*
YES
NO
What type?
Auto
Manual
Clear selection
Is there anything you would like information on?
School
Family
Training
Mental health
Work experience
Body confidence
Work
Driving
Physical health
Friends
Hobbies
Self esteem
Other:
Clear selection
How could we make BYA better?
Your answer
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