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Domestic Violence Order Application Form

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Assistance Application

"*" indicates required fields

1. Full name*

2. Date of birth*

MM slash DD slash YYYY

3. Sex*

Male

Female

Other

4. Address*

Street Address

5. Your email address*

6. Phone Number*

7. Are you Aboriginal or Torres Trait Islander*

Yes

8. Are you employed*

Yes

9. Do you have children?

Yes

If Yes, how many?

10.Tell us about your situation*

11. What do you need assistance with?*

12. What services are you currently using?*

None

Mackay Women’s Services

CASA

DV Connect

13. In order to process your application you need to attach/send a copy/photo of your drivers license or other government issued photo Identification. You can do this by *

1. Sending your photo by text to 0417 777994 or
2. Emailing to brokenballerina.inc@gmail.com

Attached

Max. file size: 92 MB.

ACKNOWLEDGEMENT*

I acknowledge the information provided above is true and correct to the best of my ability and I am aware Broken Ballerina Inc may forward relevant details to authorities if I have misled or provided false information for the purpose of fraudulently obtaining assistance.

I acknowledge that Broken Ballerina Inc has no obligation to provide any support or assistance to me/us whatsoever and may not be able to provide me/us with any assistance or only limited services/support. They may also cease providing any support/ services to me/us at anytime and I/we have no claim for breach of agreement, damages, loss or any other rights whatsoever to pursue Broken Ballerina Inc. I acknowledge that the support and services able to be provided by Broken Ballerina Inc are not by qualified professionals and is moreso short-term, emotional support and/or may include financial support by way of donations but cannot be guaranteed by them. I understand that Broken Ballerina Inc may recommend or refer me to other support services, associations etc

I acknowledge that I have not relied on any promises of support or assistance by Broken Ballerina Inc and enter into this agreement without any expectation of specific assistance or donations being provided to me.

We are committed to having a safe workplace for all staff. Any form of abuse or aggressive behaviour will not be tolerated and may impact our service to you.

I acknowledge that Broken Ballerina Inc has no obligation to provide any support or assistance to me/us whatsoever and may not be able to provide me/us with any assistance or only limited services/support. They may also cease providing any support/services to me/us at anytime and I/we have no claim for breach of agreement, damages, loss or any other rights whatsoever to pursue Broken Ballerina Inc. I acknowledge that the support and services able to be provided by Broken Ballerina Inc may not be provided by qualified professionals and is moreso short-term, emotional support and/or may include financial support by way of donations but cannot be guaranteed by them. I understand that Broken Ballerina Inc may recommend or refer me to other support services, associations etc.

I acknowledge all of my information is treated confidentially by Broken Ballerina Inc and will not be used for any other purpose than the evaluation of my request for assistance. I understand my information will not be shared with any other parties other than those directly involved with providing assistance relevant to my needs.

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Help us support survivors of Domestic Violence

Broken Ballerina Inc raises funds to provide assistance and support to survivors of domestic violence.

Being a non profit organisation we rely on grants, donations, fundraising events and sales of our merchandise to enable us to keep doing what we do for people suffering or escaping from domestic violence in Mackay and the Whitsundays.

Set up a regular 100% tax deductible donation with your bank, send us an email using the link below to tell us you have done this, and we will ensure you get a statement at tax time for your accountant.

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