Service provider sign up form

Information sharing and services coordination for children charged with offences

Required fields are marked with an asterisk (*).

Organisation name *
ABN *
Street address *
Suburb/town *
State *
Postcode *
Organisation email *
Organisation phone *
Contact person's full name *
Contact person's position *
I have read the terms of the Arrangement and confirm that: *
- the organisation is a non-government entity that provides a service to children;
- I am authorised to agree on behalf of the organisation that the organisation becomes a service provider under the Arrangement; and
- I acknowledge that the information I have entered on this form is collected for the purposes of managing the arrangement and will be made available to the Prescribed Entities and Service Providers under the Arrangement.
By clicking the submit button below, the organisation becomes a service provider under the Arrangement if it is a service provider as defined in the Youth Justices Act 1992.