Katherine Justice Reinvestment Referral Form

Youth Mentoring, Training and Employment Program

This form is used to refer a young person to the Justice Reinvestment (JR) referral for Training, and Employment Pathways Program, delivered by Savanna Solutions. The program supports young people by providing mentoring, training, and employment pathways to help build a positive future.

It collects important information about the participant, the referring agency, the participant’s background, and their support needs and interests. Consent is required from the participant—and if under 18, from their parent or guardian—for the referral to proceed.

Savanna Solutions delivers the Mentoring, Training, and Employment component of the Katherine Justice Reinvestment (JR) Program, as a Circuit Breaker activity.

First Name

Last Name

Email Address

Residential Address *

Street address *

City *

State *

Postcode *

Date of birth *

Which School do you attend *

What year are you enrolled in?

Referring Organisation *

Referring Contact Person *

Role of Referal Officer *

Email address of referal officer

Contact number for Referral Officer *

Parent or Guardian Contact Name *

Relationship to this person? *

Contact Number for Parent or Guardian *

Parent or Guardian Contact email *

Date signed

Privacy, Data Management and Child Safety Statement

Savanna Solutions is committed to safeguarding your personal information and ensuring the safety and wellbeing of all young people participating in our programs. We comply with relevant privacy laws and data protection standards, and your information will be used only for the purposes of administering the Stepping Stones Mentoring Program.

As a Child Safe Organisation, we maintain strict child safety policies and procedures. All staff working with young people have current Working With Children Checks (Ochre Card or equivalent) plus annual Police Checks. All staff have received training in child safety and respectful engagement.

By signing this form, you acknowledge that you have read and understood the above statement and consent to your child’s participation in the program.

Parent/Guardian Name

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Comments or questions.