VACAP COVID-19 Response Beneficiary profile form

LUVPAKS PARTNERSHIP

Liberian Youth Association of Victoria Inc, United Muslim Sisters of Latrobe Valley Inc, Victorian Association of Malawians & Friends Inc, Pan African Australasian Diaspora Networks Inc, AFRIAUS ILEAC: INSPIRE LEAD EDUCATE ADVOCATE FOR CHANGE Inc, Konnext RightNow and South East Victoria Women Youth and Children Association Inc.

This form will only be used by authorised members of this partnership and for the purpose as outlined below.

PURPOSE

This beneficiary profile form is used to collect and document beneficiary information from seriously impacted Victorians of African heritage and other select culturally and linguistically diverse backgrounds for the sole purpose of the effective delivery and management of the Victoria Government’s Victorian African Communities Action Plan (VACAP) COVID-19 Response Package. It is partly to meet the requirements of the VACAP COVID-19 Response Package Funding Agreement.

RESIDENTIAL STATUS (Choose all that apply)

Cultural background

What are your needs?

Capacity building

Do you have any disability?

Any dietary requirements?

Are you in quarantine due to travel or infection of the virus?

Please specify

Mental health and wellbeing support:

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.

How did you hear about us:

Checklist

14 + 2 =

Get In Touch

11 + 14 =

Pakenham Victoria 3810, Australia
Mob: +61 434 540 298
e: info@afriausileac.org

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