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A GIRLS WORLD WEEKEND

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					             A GIRLS WORLD WEEKEND
             ***APPLICATIONS CLOSE: 10th June 2009***

ABOUT YOU
Name: ___________________________ Date of Birth: ___________ Age: _____

Address:     __________________________________________________________

Phone: (h) _________________________ (m) _____________________________

Do you have any allergies, medication, additional, medical, cultural or special needs?

                                       YES          NO
Please Specify_________________________________________________________


Who could we contact in an emergency?

Name: _______________________________ Phone: ________________________

Please Note: We are able to offer a limited number of young women who are experiencing
money trouble the possibility to attend this weekend for free. Do you need to be considered for
one of these places?
                                       YES          NO

A snapshot of me now:
1. I would describe myself as?

___________________________________________________________________

2. I would describe my self-esteem as _______________________________ because

___________________________________________________________________

3. I feel _______________________________________ about being female because:

___________________________________________________________________

4. What are you really good at? What would other people say you were good at? What
helps you to be successful? What talents or skills do you have?
___________________________________________________________________

___________________________________________________________________

___________________________________________________________________
5. If you had one wish to make something happen in your life what would you wish for?

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________


6. Do you have any of these issues going on? (Please Tick)

   I have nowhere to live                Home is not a great place to be
   I need to develop more confidence     I think I have Low Self Esteem
   Issues with friends                   No Safe Adult to Talk To
   Not Many Friends                      I take too many risks
   I’m worried about my Body Image       I’m concerned about my Personal Safety
   I feel Like I Don’t Fit In            I Get Bullied
   I’m worried about my eating habits    I want to take better care of my hair/skin/body
   I worry about my relationships         I want to improve my fitness
   No Female Role Model                  Health Issue __________________________

7. What topics/issues would you most like to learn more about? (Please Tick)

   Women’s Health (periods, changes etc)        Make-Up/Skincare/Hair Care
   Diet + Eating Healthy Food                   Body Image
   Self Esteem & Confidence                     Fun Types of Exercise
   Bullying                                     Friendship
   Nutrition                                    Sexual Health
   Relationships                                Handling Tough Emotions (sadness/anger)
   Family                                       The Future (eg. Dreams/Goals)

8. What do you think are the biggest issues facing teenage girls today?
___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

9. What do you hope to get out of coming to ‘A Girls World Weekend’

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________




* Please complete the form and return it in person to the Youth Resource Centre (86
Derrimut Rd). For info contact Youth Services on: 9742 8155 (Mon-Fri / 9am-6pm).

				
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Description: A GIRLS WORLD WEEKEND