PRMC 3 LUVPACKS Beneficiary 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)Unemployed (Centrelink supported)

Home/Postal Address

Date of birth (optional)

Suburb

Email Address (optional)

Phone Number

RESIDENTIAL STATUS (Choose all that apply) RESIDENTIAL STATUS (Choose all that apply) Australian citizen Temporary resident Student: Fully funded Student: Partly funded Student: Self-funded Permanent resident Asylum seeker Other

Please specify

Cultural background Cultural background African Australian Other CALD Indigenous Australian Other

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

Please specify

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

What is your vaccination status? (You being vaccinated or not does not prevent you from accessing the Luvpakcs) What is your vaccination status? (You being vaccinated or not does not prevent you from accessing the Luvpakcs) Need more information Vaccinated Other

Please specify

How did you hear about us: How did you hear about us: AfriAus iLEAC FARREP/Monash Health Gippsland Sudanese Association Konnext RightNow Liberian Youth Assosiciation of Victoria Pan African Australasian Diaspora Network South East Victoria Women Youth & Children Association Sudanese Mothers' Coalition in Victoria United Muslim Sisters of Latrobe Valley Victoria Association of Malawians and Friends Other

Please specify how

The collected information will be used for the sole purpose of delivering and managing the CALD Communities Taskforce – Priority Response to Multicultural Communities (CALD CT-PRMC3) Program. 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 LUVPACKS 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 the CALD Communities Taskforce – Priority Response to Multicultural Communities (CALD CT-PRMC3) Program. 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 LUVPACKS Partnership to disclosing my personal information to the Sponsor as necessary for purposes of COVID-19 Response. I understand

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).