Programs & Participation Numbers Submission

Step 1 of 5

Choose from drop downs or select “Other”

Staff Name Handler

Staff Activity Handler

Region Handler

1. Program Start/Event Date*

2. Region:*

3.1 Staff Name – Metro*

3.2 Staff Name – Goldfields – Esperance*

3.3 Staff Name – Great Southern*

3.4 Staff Name – Kimberley*

3.5 Staff Name – Mid West – Gascoyne*

3.6 Staff Name – Peel*

3.7 Staff Name – Pilbara*

3.8 Staff Name – South West*

3.9 Staff Name – Wheatbelt*

3.9 Staff Name – None/Virtual*

3.1. If other, please enter staff name below:*

First

4.1. Activity Name – Metro*

4.2. Activity Name – Goldfields – Esperance*

4.3. Activity Name – Great Southern*

4.4. Activity Name – Kimberley*

4.5. Activity Name – Mid West – Gascoyne*

4.6. Activity Name – Peel*

4.7. Activity Name – Pilbara*

4.8. Activity Name – South West*

4.9. Activity Name – Wheatbelt*

4.10. If other, please enter activity name below:*

5. Activity Type*

One-off Activation

Reoccurring Program