Expression of interest To submit an expression of interest and find out more about our College please submit an enquiry below: "*" indicates required fields Agency and Student DetailsReferring Agency Contact Person School / Provider Referring 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 No Attendance 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 No How 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
