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Home › Accessing your information › Application for Release of Personal Information

Application for Release of Personal Information

MELI collects and protects personal information in line with privacy laws. Our Privacy Policy explains how we comply with these laws, how we use and store your information, and your rights regarding access and correction. To learn more, visit www.meli.org.au/privacy-policy, or ask for a copy to be sent to you. To apply for personal records, complete this form and provide photo identification (such as a driver’s licence, birth certificate, or passport). This helps us confirm your identity, protect personal data, and ensure you have the legal right to access the requested records. If your name has changed due to marriage or other legal reasons, and you are now known by a different name, please include supporting documents showing the change of name. If you want someone else to request or receive this information on your behalf, complete the Third-Party Information Release Authorisation section on the last page.

"*" indicates required fields

Step 1 of 5

20%

Details of the Person Making the Enquiry

Full name*

First Name Surname

Mobile Phone*

Home Phone

Email*

Postal Address*

Street Address Address Line 2 City State Post Code Country

Relationship to Person in Request*

Details of the Person Who Received Meli Services

Meli services includes the services that came together to form Meli, including Bethany; Barwon Child, Youth and Family; Glastonbury Child and Family Services; Barwon Youth/ BAYSA; Time for Youth; and Northern Futures. There may be other services and programs in addition to these.

Full name*

First Name Surname

Any Previous Names?

Date of Birth*

DD slash MM slash YYYY

Place of Birth*

Birth Mother’s Name*

Birth Father’s Name*

Type of Services Involved with*

Reason for Request

Please provide a brief explanation of why you seek the information and/or whether this request for information specifically relates to obtaining health information. Please include whether you are seeking your entire record or a specific part of your record, for example, a specific report(s) or for a specified time frame etc. We ask this question to better understand the purpose of your request and ensure we provide the most relevant and accurate information. While answering is optional, your response can help us locate the correct records more efficiently, especially if your request relates to specific health information or other sensitive details.

Reason for Request (Optional)

Identification Requirements

Identification is necessary to verify your identity and ensure that only the correct person receives access to their personal records. This helps protect your privacy and prevent unauthorised access. This is a legal requirement.

Primary Identification*

(One Required)

Select at least 1 choice.

Birth Certificate

Driver’s Licence

Passport

Evidence of Age / Key Pass

Please provide a copy of your selected identification document*

Drop files here or

Max. file size: 100 MB.

Affirmation and Signature

By submitting this application, I affirm that the facts set forth in it are true and complete.

Consent 2*

I acknowledge that the file remains the property of Meli; however, where appropriate, copies of relevant documents or information will be provided.*

Consent 1*

I authorise Meli to conduct the necessary searches and release the requested information to me.*

Consent 3*

I acknowledge that Meli reserves the right to withhold information that may compromise the safety and wellbeing of others.*

Signature*

This field is hidden when viewing the form

Date*

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We acknowledge that we work and connect on the traditional and unceded lands of Aboriginal peoples and pay our respects to their Elders past and present.

We are committed to the reconciliation journey through our actions and openness to learn.

Meli is committed to creating an environment where everyone feels safe and that they belong.

We welcome people of all races, ethnicities, genders, sexual orientations, ages, religions, abilities and nationalities and value diversity of experience as a vital part of supporting people and strengthening communities.

We will listen, learn and evolve as an accessible, inclusive and safe organisation for all, including First Nations peoples, members of the LGBTQIA+ community, people with a disability and those with culturally diverse backgrounds.

Meli respects and values the diverse knowledge, experiences and perspectives of people who access our services. We commit to actively supporting lived experience inclusion and leadership. We strive to ensure that decision-making at all levels of our organisation is shaped by the rich and specialist expertise of lived experience.

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