10-12 Albert Street,

Geelong West 3218

Phone : (03) 5221 2984

Fax : (03) 5223 1789

Email :

VOLUNTEER/STUDENT APPLICATION FORM

POSITION APPLIED FOR:______

PROGRAM/SERVICE:______

Full Name: / Please list names of adults (18+) who live with you
Address:
Postal Address:
Phone No(s): / Mobile:
Home:
BH:
Email:
Emergency Contact Name: / Contact Number:

If you have lived outside of Australia for more than 12 months in the last 10 years, you will be required to supply an international police check from the country where you lived. Volunteering/ Student Placement cannot commence until this check is received and assessed. Information on how to obtain this is found at

Is an international police check required?

Yes No

Current employer:

(Name & Address)

Position:

Full Time Part Time Casual

Volunteer Other

What experience have you had with children?

Have you looked after children before? Yes No If yes, in what capacity?

Please give details of any experience with children or young adults with a disability

Tell us about your hobbies and interests?

Please give details

Have you been involved in Volunteering before? YES NO If yes, where?

What are your reasons for wanting to become a Gateways Support Services Volunteer?

Do you have any education or training which may be relevant to this application (eg: First Aid, Secondary/Tertiary

Education)? ______

You must read the position description before answering this question.We request that you disclose any pre-existing injuries or diseases of which you are aware and you could reasonably expect to affect the nature of the position you are applying for.

In this position you may be required to:

  • Walk distances and / or move quickly
/
  • Support clients to transfer

  • Push wheelchairs or trolleys
/
  • Support and supervise clients

  • Lift or move some objects

Have you any medical history, pre-existing illnesses, diseases, physical or psychological conditions, which could be aggravated by the type of position you are applying for? YES / NO

If yes, please give details

Licence Number:Date of Expiry:State of Origin:

Licence Type:No of years held:

Have you ever been convicted of a driving offence? YES NO

Please give details:

Please provide details of any motor vehicle accidents in which you were involved as a driver during the last two years:

Is your car currently roadworthy?YES NO

Is your car currently insured?YES NO

CONFLICT OF INTEREST

You are required to disclose knowledge of a relative, friend or someone you have an acrimonious relationship with who is working at Gateways to enable Gateways to assess whether the connection or reporting line may give rise to a perceived or potential conflict of interest.

Name of Gateways employee who may give rise of a conflict of interest

Relationship to the Gateways employee

I have no knowledge of a relative or friend at Gateways who may give rise to a conflict of interest

Please provide two (2) referees who you authorise us to contact. Referees must have known you for at least 12 months and should not be family members. Referees will be contacted after the formal interview process.Include at least one professional referee.

Name:______/ Name:______
Address:______/ Address:______
Telephone:______/ Telephone:______
Relationship to Applicant______/ Relationship to Applicant______

In addition to complying with the relevant legislation, policies and procedures under which Gateways Support Services conducts its business, volunteers and students are expected to follow acceptable standards of conduct in relation to their activities, dealing with clients, client’s families, staff, other volunteers and students, the public and the property of the agency and clients.

The following points describe the Code of Conduct in general terms. All volunteers and students are expected to:

  • Display skills care and diligence in the performance of their duties.
  • Observe the rights of all clients/participants to respect, dignity and privacy.
  • Behave in a courteous manner to staff, clients, fellow volunteers and students and the public.
  • Observe confidentiality in regard to any information concerning the agency or its clients that is

gained during the course of their volunteer activities or student placement.

  • Respect the property of the agency, staff, clients, other volunteers and students and the public.
  • Comply with the prescribed terms and conditions of their volunteer role/student placement.
  • Observe safe work practices so as not to endanger themselves or others.
  • Work under the direction of program staff.
  • Be punctual and reliable in their attendance.
  • Be clean, neat and tidy in their appearance.
  • Follow documented agency grievance processes.
  • Do not steal property belonging to the agency, its staff or clients, or make false declarations.
  • Do not use agency property in an unauthorised manner.
  • Notify the agency if the volunteer or student is charged with a criminal offence.
  • Report to the agency if there is a potential conflict of interest between the volunteer or student’s

activities with the agency and existing or proposed outside employment/placement/activities.

  • Do not consume any intoxicating substance while participating in a program or attend affected by

any substance.

  • Do not solicit or seek gifts from clients or members of the public for performing their duties.

I, (name) declare this Volunteer Application to contain true and correct information and consent to any reference checks which may be necessary to support this application.

I agree to undertake a police checkas a safety screening process which is a mandatory requirement of the funder or Gateways.

If my application is successful, I agree to be bound to Gateways Code of Conduct above. Should it be proven that any answers given by me as part of this application are incorrect or I have breached the Code of Conduct I will accept Gateways right to immediately terminate my involvement with Gateways Support Services Volunteer Program.

Signature of Applicant: Date:

Signature of Witness: Date:

Form 2800 GF1 Volunteer/Student Application Form 23/01/2015 Version 3 1

Form location – F:\shared\Gateways Policies, Procedures & Forms\Gateways Forms\2000 All Staff, Volunteers & Students\2800 GF Volunteers & Students