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SARC Women’s Safety Program Enrolment
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Step
1
of 2
Contact Details
Name(This field is mandatory)
Preferred Name
Address(This field is mandatory)
Address Line 1
City
State / Province / Region
Postal Code
Phone(This field is mandatory)
Email(This field is mandatory)
Emergency contact
About You
Date of Birth
Are you 18+ years of age?
Yes
No
Country of Birth
Employment Status
Full-time
Part-time
Casual
Working visa
Student
Looking for work
Not looking for work
Other
Employment Status
Main Language Spoken at home
Allergies/ Food Intolerances (for catering purposes)
Are you (or do you identify as) a woman?
Yes
No
Are you of Aboriginal and/or Torres Strait Islander origin?
Yes
No
Do you live in Canberra or Surrounds (eg., Queanbeyan, Yass, Goulburn)
Yes
No
Are you willing and able to undertake travel on a weekly basis to attend the classes? This includes classes on a Tues or Thurs, plus some Sundays.
Yes
No
Program eligibility category
Why we ask these questions? The Women's Safety Program is funded by one of the Department of Social Services' (DSS) Strong and Resilient Communities Activity - Inclusive Communities (SARC) grants which exist to: "support vulnerable and disadvantaged people on pathways to self-reliance and empowerment through local community-driven solutions that support them to participate socially and economically". The SARC Women's Safety Program was developed as a preventative program for women with disability, impairment or are in a 'vulnerable' or 'at-risk' category. We ask these questions as a screening tool to ensure eligibility, but also for reporting purposes to DSS. Information reported to DSS is done in an anonymous way to respect the privacy of individuals so that no personal identifying information is provided with demographic statistics.
Sensory impairment / Disability (Tick all that apply)
Vision Impairment
Hearing Impairment
Low Vision / Blind - with white cane
Low Vision / Blind - with Guide Dog
Deaf / Hearing Loss
Autism Spectrum Disorder
Other sensory impairment / disability
Other sensory impairment / disability
Physical Disability (Tick all that apply)
Injury - related
Cerebal Palsy
Epilepsy
Multiple Sclerosis
Other Physical Disability
Other physical disability
'Vulnerable'/ 'at-risk' category (Tick all that apply)
Chronic health condition
Diagnosed mental illness
Mental health difficulties or issues
Single parent / pregnant with domestic stress
LGBTQI+
Refugee / migrant / asylum seeker
Culturally / linguistically diverse background
Aboriginal / Torres Strait Islander
Unemployed / unable to work
Partner / family with addiction
Victim of violence / sexual assault
Victim / witness of violence in the home
Financially dependent on others
Grew up in abusive household
Childhood experience of homelessness
Childhood / lived experience of trauma
Childhood / lived experience of bullying
Under financial hardship
Other
Other
Accessibility Needs
Do you have any accessibility needs or requirements?
Will you have a support person/carer attending the sessions with you?
Yes
No
Unsure
Will you have a Guide Dog, Assistance/Service Dog, or Emotional Support Dog with you?
Yes
No
Unsure
Safety Concerns
Do you have any safety concerns or requirements that you many require assistance with?
Are you currently in an unsafe or crisis situation?
Yes
No
Unsure
Do you need information or would you like to speak to someone about crisis services?
Yes
No
Unsure
Workshops
Which 12-week group do you want to enrol into?
First Available Group that has availability
Group 1 - Tuesdays: 21 Feb - 02 May 2023
Group 2 - Tuesdays: 6 June - 22 Aug 2023
Group 3 - Thursdays: 10 Aug - 26 Oct 2023
Group 4 - Tuesdays: 12 Sep - 28 Nov 2023
Group 5 - Tuesdays: 06 Feb - 23 Apr 2024
Group 6 - Thursdays: - 07 Mar - 21 May 2024
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