Program Details Where did you hear about this program? Preferred Venue Online Armidale Baulkham Hills Bexley North Bomaderry Bowral Byron Bay Campbelltown Coffs Harbour Cooma Dubbo East Maitland Engadine Frenchs Forest Gosford Goulburn Kiama Leichhardt Lidcombe Lismore Liverpool Liverpool – Arabic/Vietnamese Macksville Marrickville North Ryde Orange Parkes Penrith/Nepean Port Stephens Queanbeyan Springwood Sydney CBD Sydney CBD - Chinese Townsville NSW Tweed Heads Valentine Waratah Brisbane Ingham Townsville QLD Toowoomba Adelaide Fleurieu Peninsula Mt. Gambier Albany Balga Busselton Geraldton Kalamunda Mandurah Midvale Mount Lawley Riverton South Bunbury Success Wanneroo Warnbro View a map of available venues to find your nearest program location. Personal Details First Name Last Name Date of Birth Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Address * Country * AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong S.A.R., ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe Address Address 2 City/Suburb State - None -Australian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia Postcode Home Phone Work Phone Mobile Email * Preferred communication method * Email Text Message Phone We are supportive of women with cultural and disability needs. Please let us know how we can help – 02 9285 6264. Country of Birth Are you Aboriginal or Torres Strait Islander? Yes No Language Do you speak a language other than English at home? No Yes - Which language/s do you speak at home Language Yes - Which language/s do you speak at home Disability We are committed to meeting disability or other support needs to assist you to participate in the Encore program. Please tick any of the following boxes if applicable. You will be contacted for more information prior to the course. Hearing impairment Visual impairment Other Disability Do you have / live with a disability? Please describe your disability? Carer Do you have a carer who will also be attending the program? Yes No Emergency contact First Name Last Name Relationship Please define how your are related to your emergency contact, ie, sister, brother, friend. Phone Agreement Consent Form I wish to enrol in the YWCA Encore program facilitated by YWCA Australia. In doing so, I waive all and any claim, right or course of action against YWCA Australia, its officers and servants for any accident, or illness, which occurs during participation in the YWCA Encore program. I further authorise the said officers or servants of YWCA Australia to administer first aid and/or procure medical assistance, as they may determine necessary, in the event of any illness or accident that may occur whilst attending the YWCA Encore program, and agree to meet any expenses incurred therein. Authorise Agreement * I consent