Victims' Register - Youth Offenders Application Form

1. Do you wish to nominate someone (a nominee) to receive information on your behalf? *

   -- Please Select --YesNo

1. Full name *
2. Organisation (if applicable)
3. Postal address *
4. Phone *
5. Email *
6. Preferred contact method

   -- Please Select --PostPhoneEmail

1. Full name *
2. Date of birth *
3. Postal address *
4. Phone *
5. Email *
6. Preferred contact method

   -- Please Select --PostPhoneEmail
7. Communication considerations For example: Do you require interpreter, is it safe to contact you on all methods above? etc.
8. I am *

   • The parent of the victim who is a child (including parent, guardian or person who has lawful custody or the day-to-day care and control of the child).
   • The guardian of the victim who is an adult with legal incapacity (including attorney appointed for the victim under an enduring power of attorney under the Powers of Attorney Act 1998).
   • A person whose life or physical safety could be endangered because of the young person’s history of violence against me.
   • A person whose life or physical safety could be endangered because of a connection between me and the offence.

1. Name of child victim *
2. Date of birth *
3. Your relationship to the child *

Please provide proof, along with your identity documents, of your status as guardian/attorney later in this form.

1. Name of victim with legal incapacity *

1. Young person name *
2. Young person date of birth (if known)
3. Other identifying information about the young person (if known), e.g. address, aliases, current location, etc.
4. Please provide some information about the history of violence * (just enough for us to understand the situation)
5. Have you made any reports to police, and if so, do you have a QP number? *
6. I understand that it may be necessary to inform the young person that a person has made an application for the Victims’ Register – Youth Offenders to allow the making of a submission under section 282BA(4) of the Youth Justice Act 1992. I understand that the Victims’ Register team will contact me before this happens.

   -- Please Select --YesNo

1. Please provide some details about your connection to the offence * Please note that specific offence details are to be provided below.
2. I understand that it may be necessary to inform the youth that a person made an application for the Victims’ Register – Youth Offenders to allow the making of a submission under section 282BA(4) of the Youth Justice Act 1992. I understand that the Victims’ Register team will contact me before this happens.

   -- Please Select --YesNo

1. Offence title
2. Offence date
3. Offence location
4. Queensland Police (QP) number
5. Any other information which may help us identify the offence
6. ODPP file number

All applicants must provide identifying documentation.

1. Proof of identity * Photo/photocopy of a document that has your name, address and signature (e.g. passport or driver’s licence). Maximum 3 files.
2. Proof of guardianship * If applying as the guardian/attorney of an adult victim with legal incapacity, you must provide proof that you are the guardian of the victim, or an attorney appointed for the victim under an enduring power of attorney under the Powers of Attorney Act 1998.

I, (your name), request that my details be entered into the Victims’ Register – Youth Offenders, governed under Part 8, Division 7 of the Youth Justice Act 1992 and managed by the Department of Youth Justice and Victim Support (DYJVS).

I understand and accept that my details will be kept on the register until I notify in writing that I wish to be removed or if any of the following occurs:

• the relevant youth:
  • is discharged from detention
  • is released on a supervised release order and the order ends
  • dies while in detention
  • is transferred to another jurisdiction or a corrective services facility
• the relevant conviction is overturned.

I understand and accept that I may also be removed from the register if:

• DYJVS are unable, after reasonable efforts, to contact me
• I share information unlawfully.

I understand and accept that the information supplied through the register is confidential and agree to handle this information as per section 282G(3) of the Youth Justice Act 1992. I agree not to disclose the information I receive as part of my registration to another person unless the disclosure is:

• for the Youth Justice Act 1992 or to discharge a function of another law
• authorised by another law or the young person to whom the information relates
• for a proceeding in a court and I am required to do so by order of the court or otherwise by law
• reasonably necessary to obtain counselling, advice or other treatment.

I understand and accept that the maximum penalty for unlawful disclosure is 100 penalty points or two years imprisonment.

I understand and accept that if I choose not to disclose my home address, or fail to advise of a change of address, that the DYJVS may not be able to provide a complete service to me.

I understand that it may be necessary to inform the youth that a person has made an application for the Victims’ Register – Youth Offenders to allow the making of a submission under section 282BA(4) of the Youth Justice Act 1992. I understand that the Victims’ Register team will contact me before this happens.

I consent to the information I have provided being shared with the Office of the Director of Public Prosecutions or Queensland Police Service to verify details of my application and/or identify the youth who has been sentenced for the relevant offence.

I understand the DYJVS will contact me if there is a requirement to share my information with anyone other than the Office of the Director of Public Prosecutions or Queensland Police Service, other than that listed in sections 'Details of history of violence' and 'Details of your connection to the offence' of this application form.

1. I understand and consent to the above *

   • I understand and consent to the above