APPLICATION FOR REGISTRATION AS A VOLUNTEER Title: Mr / Mrs / Ms / Miss Name: (please also list preferred name for volunteer badge) J:\COMMUNITY SERVICES\ADMINISTRATI ON\VOLUNTEERS\Forms\ Application Forms\CURRENT VOLUNTEER application Form 2012.docOFFICE USE ONLY Interview booked: Date & location Drivers Licence Police Check WWC Referee Check Letter Database Badge Start Date Program/service Address: Suburb: Postcode: Phone: (H) (W) (M) Email: Date of Birth: (volunteers must be aged 18 or over) Languages other than English: Country of Origin: Are you a Permanent Resident of Australia? Yes No Note: applicants must be a Permanent Resident to be eligible to volunteer at the City of Bayswater. Emergency Contact: Relationship: Tel: Please list below one person (not a family member) we can contact that will be able to give us a character reference for you. If possible, provide the name of a professional associate. Referee 1: Relationship: Tel: How did you find out about the City of Bayswater volunteer program? City of Bayswater website City of Bayswater brochure or poster SEEK website Go Volunteer website Other (please specify): 1
When you bring this form to the City of Bayswater, you will also need to bring a form of identification showing your current address Which days would you be available for voluntary work? Please tick Day Morning Afternoon Evening Monday Tuesday Wednesday Thursday Friday Saturday Sunday Do you anticipate being available to volunteer in the role for at least 3 months? (note: preference may be given to volunteer applicants who can commit to the role for a longer time) Please list any work skills you may have e.g. languages or computer skills etc: Please list any interests or hobbies you may have e.g. arts and crafts etc: Do you have sound communication skills? Have you done volunteer work before and if so, what type? What areas of voluntary work are you interested in? Volunteer Work Adult Day Centre Olive Tree House Bayswater Library - Books on Wheels Bus Driver Good Companion Group Maylands Library - Books on Wheels Meals on Wheels Assistant Meals on Wheels Driver Morley Library - Books on Wheels Please tick 2
Social Support Programme/Shopping Assistance Bayswater Leisure & Information Service -Younger Disabled Programme Youth Advisory Committee PAWS Pets and Wellbeing Programme Other positions you may be interested in Please state Would you be interested in relieving for other volunteers on occasional days if they are unwell or away for any reason? Yes No If yes, which days would you be available to relieve? Day Morning Afternoon Evening Monday Tuesday Wednesday Thursday Friday Saturday Sunday Would you like to visit the volunteer program for a short tour before applying for the position? Yes No Are you currently Employed Full Time Employed Part Time Employed Casual Retired Student Workers Compensation Pension Self-Employed Home Duties Unemployed Visitor Sick Leave Seeking employment Other 3
Some volunteer positions may be able to involve persons under 18 years of age, on the condition the minor is supervised by their parent/guardian at all times. Please sign your consent below to agree to the terms and conditions set out above. Parent/Guardian Name Signature Minor's Name Signature In the case of any medical emergency, the City of Bayswater has a duty to ask you for the following information: Do you suffer from any medical condition that may effect you carrying out your volunteer work? e.g. heart problem, bad back, vision impairment, depression etc. No / Yes If yes please state: List any medication you are on that may affect your volunteer work. Please state how it may affect you: Do you have Private Health Cover: Yes / No Fund Name: Information for Volunteer Bus and Car Drivers For those volunteers who will be driving a bus with more than 12 seats for the City of Bayswater, we require a copy of your current Class 'LR' licence. For those volunteers who will be driving a car or a bus seating 12 or less person for the City of Bayswater, we require a copy of your current Class 'C' licence. Car Make: Car Model: Year: Number Plate: Car Insurance: 3 RD PARTY ONLY FULLY COMPREHENSIVE (Name of Insurance Company) I declare that the above is true and correct, and I will endeavour to keep my vehicle in a roadworthy state. I understand that the City of Bayswater s insurance covers me as a volunteer for public liability and severe personal accidents while performing volunteer work, but does not 4
cover me for minor accidents or my vehicle or any other vehicle involved. It is my responsibility to consult my insurance company. Should I change vehicles at any time I will inform the City of Bayswater. When you bring this form to the City of Bayswater, you will need to bring your current driver s licence with you REMINDER: If you are using your vehicle for volunteer work for the City of Bayswater, we remind you to inform your insurance agency of the use. Due to the nature of our clients and the type of work we do, it is our moral and legal responsibility that we ask all volunteers to obtain a Police Clearance. The City of Bayswater can obtain a national police check at no cost to you. An Application for Volunteer National Police Check form will be provided to be completed by you. The officer can then submit the information for clearance. Please note: Having a criminal record does not necessarily exclude you from joining us as a volunteer. This depends on the conviction and the type of volunteer work that will be undertaken. Do you have a criminal record in Western Australia or elsewhere? No / Yes If no, the following statement applies: I do hereby declare that I do not have any police convictions of the type that would preclude me from undertaking volunteer work with the City of Bayswater. I do not, therefore, have any convictions that include crimes involving drugs, theft, fraud, breaking and entering, violence or careless driving. If yes, please specify type and date of convictions: TERMS OF VOLUNTARY DUTY a) As an official volunteer of the City of Bayswater I acknowledge that I am subject to the volunteer Code of Conduct. I assume certain responsibilities and expect to be accountable for my actions, in terms of what is expected of me. b) I also understand that confidentiality is of the utmost importance and agree to keep all matters confidential. c) I interpret voluntary duty to mean that I have agreed to offer my services on the understanding that no financial remuneration will be received in return for them. d) In case of an accident, I hereby grant the City of Bayswater or an official representative of the Council, permission to call an ambulance, doctor, or next of kin on my behalf. e) I agree report any Police Conviction and/or Traffic Infringement to Manager, Community Services. f) I acknowledge that I have the following responsibilities as a volunteer: Be dependable notify the agency if unable to attend. Be willing to undertake relevant orientation, training, support and supervision. 5
Be non-judgmental Work in accordance with health and safety regulations. Work in accordance with the agency s policies, procedures, instructions and rules. Say no when you cannot commit to a task. Respect the rights, privacy and dignity of clients and colleagues. Signature: Date: Please return completed form to: Email: mail@bayswater.wa.gov.au Fax: (08) 9272 0665 Post: PO Box 467, MORLEY WA 6943 Deliver to: 61 Broun Avenue, MORLEY WA 6062 OFFICE: Does the voluntary work involve any of the following: Working with children aged 0-7years Yes / No Working with children aged 8-12 years Yes / No Working with children aged 13-18 years Yes / No If any of the above applies, notify the volunteer they need to obtain a Working with Children Check. 6