Local Government Australia Day Ambassador Program 2018 Registration Please complete the online registration form below and submit by Wednesday 6 December 2017. If you are human, leave this field blank. Registration Details Organisation (City/Shire Name) * Contact person (Full Name) * Position * Postal Address * Suburb * Postcode * Phone Number * Mobile Number * Email Address * Alternative Contact person (Full Name) * Alternative Contact person - Phone Number * Planned activities for Ambassador NOTE: Please submit a separate form for different towns. Include time commitment, event location, activities involved and expected attendance numbers Event Location (e.g. Council Offices, Torquay) * Event date and start time / end time Activity (e.g. Flag Raising Ceremony, followed by community BBQ) * Expected attendance numbers (e.g. 500 people) * Ambassador Preferences Australia Day Ambassadors are icons of culture, sports, arts, health among other fields. Please tell us if you're interested in hosting an Ambassador from a particular background or field - where possible, we will try to match allocations to your preference. Areas of Interest Ability/disability Advocacy Arts Business Defence Forces Education Emergency Services Entrepreneurship Environment Fashion Health Hospitality Indigenous LGBTI Media Media personality Medicine Music Multiculturalism Philanthropy/charity Politics Reconciliation Recreation Religion/faith Returned Serviceperson Science Seniors Sport Social services/advocacy Volunteering Women’s advocacy Youth I understand that my city/shire may be required to cover the costs of the Ambassadors' accommodation and incidentals for their visit to our event/s * Yes, I understand Please submit by Wednesday 6 December, 2017
