Expression of interestTo submit an expression of interest and find out more about our College please submit an enquiry below:"*" indicates required fieldsAgency and Student DetailsReferring Agency Contact PersonSchool / ProviderReferring Agency Email Address PhoneStudent First Name*Student Last Name*Date of Birth MM slash DD slash YYYY Gender*Please selectMaleFemaleOtherStudent AddressAddress*Suburb*State*Please selectVICNSWSATASQLDWANTPostcode*Parent/Guardian Contact DetailsParent/Guardian Name*Parent/Guardian Last Name*Relationship to student*Phone*Email Address* Educational DetailsIs the student attending secondary school?* Yes NoAttendance at current school* Under 20% 20 - 40% 40 - 60% 60 - 80% Above 80%Brief reason/s for leaving school*Please selectAcademic PerformanceRelationship breakdown with peers and/or schoolHealth/Mental Health issuesBullying/HarassmentLearning NeedsFamily IssuesSuspension/ExpulsionOtherOther:Does the student receive any specialist services or education support?* Yes NoHow did you hear about Y2IC?How did you hear about Y2IC?Victorian School / Career Practitioner / VET CoordinatorYouth Mental Health ServicePsychologistNDIS ProviderYouth Service AgencySearch EngineOnline AdvertisingSocial MediaWord of MouthCAPTCHA
