Leadership Academy Application Form Leadership AcademyPlease complete the application form below.Step 1 of 4 - PART A: Personal details25%PART A: Personal detailsSurname(Required)TitleTitleMrMrsMsMissFirst Name(Required)Also known asGenderGenderFemaleMaleDate of Birth(Required) DD slash MM slash YYYY Residential Address(Required) Address City State Postcode Postal address same as residential address Yes NoPostal Address(Required) Address City State Postcode Home PhoneWork PhoneMobile PhoneEmail address(Required) Emergency contactEmergency Contact NameRelationshipEmergency Contact Address(Required) Address City State Postcode Emergency Home PhoneEmergency Work PhoneEmergency MobileIdentityAre you Aboriginal and/or Torres Strait Islander origin? Aboriginal Torres Strait Islander Aboriginal and Torres Strait Islander non-Indigenous(For persons of both Aboriginal AND Torres Strait Islander origin mark both boxes)Associated Community Aurukun Bamaga Coen Cooktown Hope Vale Injinoo Kowanyama Laura Lockhart River Mapoon Mossman Gorge Mossman Napranum New Mapoon Pormpuraaw Seisia Umagico Weipa Wujal Wujal Yarrabah OtherDo you speak a First Nation language at home Yes NoIf yes, please advise the main language spoken at homeDo you have a Blue Card (working with children)? Yes NoDo you have a Drivers Licence/Learners? Yes NoIf you have a licence indicate what it is?Open LicenceProvisional LicenceLearnersAre you a past participant of any of the following leadership programs? Please tick all that apply. Cape York Leadership Academy 2005-2012 CYLP Academic Leaders Secondary CYLP Academic Leaders Tertiary CYLP Youth Leaders CYLP Skilling Leaders CYLP Excelling LeadersPART B: Employment detailsEmployment Status(Required) Employed Unemployed Looking for workPosition / Role(Required)Employer Name(Required)How long have you been employed with your employer?(Required)Trainee / Apprentice Trainee ApprenticeTraineeship / Apprenticeship NameEmployment Type Full Time Part Time CasualSupervisors detailsSupervisors NameSupervisors Email Supervisors PhoneSupervisors MobilePART C: Education and TrainingLeadership Development Reason To get a job It was a requirement of my job I wanted to learn new skills for my job To get a promotion To start my own business I want to become a CEO of a company To gain a qualification For personal interest To explore different career options To be advocate and change maker for Indigenous peoplePlease indicate your reason to join the Academy.Do you have a Unique Student Identifier number (USI)? Yes No MaybeHighest level of education Year 12 Certificate I Certificate II Certificate III Certificate IV Diploma Advanced diploma Graduate certificate Graduate diploma Bachelor’s degree Bachelor Honours Degree Master’s degree Doctoral DegreeSelect the level of education you have achieved.Qualification Name(Required)Licenses and Tickets Building and Construction Mining Energy, Oil, Gas Agriculture Education Environment Health Retail OtherDo you hold any tickets and/or licences in the following industry and/or sectorsLicense/Ticket Name(Required)Learning Support Yes No MaybeDo you believe you may require some assistance to complete any qualifications or workshop activities?Can you think of any social, emotional and wellbeing challenges that could affect your learning? (For example, medical, health, disability, eyesight, hearing).Can you think of any language, and cultural challenges that could affect your learning? (For example, cultural and clan responsibilities, language)Learning Devices Yes NoDo you have access to a working and reliable laptop, computer or other device that is connected to the internet, to complete projects, connect, collaborate, co-design and share insights.PART D: Career Interest SurveyTick which best describes you (Tick one or more) REALISTIC Hands-on, Doers: I am interested in practical things that I can see, and touch and I like hands-on work activities. I like working with either plants, animals, and/or real-world materials such as wood, tools and machinery. INVESTIGATIVE Problem solvers, Thinkers: I am interested in work that involves investigating, coming up with ideas and thinking about solving things rather than physical activity. I like to search for facts and figure out problems, I like working with ideas and data. ARTISTIC Creativity, Creators: I am interested in work that deals with being creative, such as acting, music, art and/or design. I value self-expression and I am not interested in highly structured and repetitive work. I like to work with ideas and be creative and imaginative. SOCIAL Collaborators, Helpers: I am interested in working with people and this can be by teaching, advising, helping and being of service to people. I like talking and being social with others and building relationships with a range of different people. ENTERPRISING Decision-Making, Persuaders: I am interested in working with people that involves starting up and carrying out projects. I like taking actions rather than working with data. I like to persuade and lead people, making decisions and taking risks. I like to be with people from other teams by engaging with them, implementing the works and executing it. CONVENTIONAL Decision-Making, Persuaders: I am interested in work that follows set procedures and routines. I like to have structure and order. I like working with data and I have attention to details.
