VACAP COVID-19 Response Beneficiary profile form

Given names

Language(s) for effective communication (written & spoken)

Preferred name(s)

Number of people in your household (including adults and children):

Title TitleMrMrsMissMsDrOther

Status StatusSingleMarriedDe factoChoose not to say

Age Age16 – 1819 - 2526 – 3233 – 4041 – 4950 – 5960 – 6566 and Above

Employment Status Employment StatusEmployedUnemployed (Jobseeker)Unemployed (lost job)Unemployed (other)

Home/Postal Address

Date of birth (optional)

Suburb

Email Address

Phone Number

RESIDENTIAL STATUS (Choose all that apply) RESIDENTIAL STATUS (Choose all that apply) Australian citizen Temporary Student: Fully funded Student: Partly funded Student: Self-funded

Cultural background Cultural background African Australian Other CALD Indigenous Australian Other

What are your needs? What are your needs? Food Personal items

Please specify

Capacity building Capacity building Yes No

Do you have any disability? Do you have any disability? Yes No

Please briefly explain

Any dietary requirements? Any dietary requirements? Yes No

Please briefly explain

Are you in quarantine due to travel or infection of the virus? Are you in quarantine due to travel or infection of the virus? Yes No

Please specify Please specify 1-7 days 8-14 days

Mental health and wellbeing support: Mental health and wellbeing support: Yes No

The collected information will be used for the sole purpose of delivering and managing Victoria Government’s VACAP COVID-19 Response Package. Hence, I a) Have read the information in this form/The information has been read to me and I understand it. b) Understand this information remains valid for the use of the specified Activity. c) Consent to LUVPAKS Partnership to disclosing my personal information to the Sponsor as necessary for purposes of COVID-19 Response. The collected information will be used for the sole purpose of delivering and managing Victoria Government’s VACAP COVID-19 Response Package. Hence, I a) Have read the information in this form/The information has been read to me and I understand it. b) Understand this information remains valid for the use of the specified Activity. c) Consent to LUVPAKS Partnership to disclosing my personal information to the Sponsor as necessary for purposes of COVID-19 Response. I understand

How did you hear about us: How did you hear about us: FARREP Liberian Youth Assosiciation of Victoris Victoria Association of Malawians and Friends United Muslim Sisters of Latrobe Valley Pan African Australasian Diaspora Network AfriAus iLEAC Coach Trainer Academy South East Victoria Women Youth & Children Association Konnext RightNow Other

Please specify how

Checklist Checklist I have read the information in this beneficiary form/The information in this beneficiary form has been read to me and I understand it. I have completed all the sections of this form. Any corrections have been initialled and dated by me (or assistant).