You are here: Home › Mission › Bellarine Salvos Outreach Van › Bellarine Salvos Outreach And Emergency Services Adult Volunteer Registration Form Bellarine Salvos Outreach and Emergency Services- Adult Volunteer Registration Form Medical and Personal Information Form I want to volunteer with:-- Please Select -- The Bellarine Salvos Outreach Van Bellarine Salvos Emergency Services Both Services Personal Contact Details Given Name: Surname: Preferred Name: Gender: Male Female Intersex/Unspecified Address: Suburb: Postcode: Phone: * Email Address: * Confirm Email Address: * Highest Level of Education: Year 9 Year 10 Year 11 Year 12 Certificate I Certificate II Certificate III Certificate IV Diploma Degree Masters Other Education: I am Currently - : Working Full Time Working Part Time Working Casual Looking For Work Not Working Do you identify as: Aboriginal Torres Strait Islander Do you consent to appropriate use by us of photographs taken on the program that include you? For example, inclusion in social media, Salvation Army internal and external media use.: Yes No Safety and Care Details Emergency Contact: Relationship to you: Phone: * Information on Relevant Conditions Are there any conditions which require special attention that we should know about, e.g. hearing or sight impairment, mental health issues, formal counselling situations, or any other? Please list:: Medical Information Insurance Provider: Membership Number: Medicare Number: Number of Person on Medicare Card: Expiry Date: Health Care Card Number: Do you have ambulance cover?: Yes No Will you need to take any tablets or other medication during the course of the program?: Yes No If yes please give details: Have you been taken off medication recently? : Yes No If yes please give details: When was the year of your last tetanus injection?: Have you previously broken/fractured any bones?: Yes No If yes, please give details: Specific Medical Conditions: Asthma Appendicitis Bronchitis Chicken Pox Diabetes Ear Infections Epilepsy Fits/Convulsion Faint/Dizziness Glandular Fever Hyperactivity Hypo Activity Heart Problems Measles Mumps Pneumonia Tonsillitis Allergy - foods Allergy - Animals Allergy - other any additional details if necessary: Particular Activities In attending the program, you consent to participation in a range of physical activities including walking in the dark with torches. If potentially risky activities of a specific nature are included, the Team Leader will inform you of these. Are there any specific activities that you do not wish to participate in?: * Yes No If yes please specify: Your Agreement With The Organisation I am aware, in signing this document regarding my participation in this program, that certain elements of the program could be physically and emotionally demanding. Furthermore, I understand that certain inherent risks and dangers exist in the activities in which I will be participating. I acknowledge that while the organisation and its leaders will make every reasonable effort to minimise exposure to known risks, all hazards and dangers associated with these activities cannot be foreseen or may be beyond the control of the organisation, its leaders and staff. In the event of any emergency where my nominated contact people are unavailable: I authorise the leaders to obtain medical advice and/or assistance which they deem necessary. I further authorise qualified practitioners to administer anaesthetic if required. I accept all operation, blood transfusion and/or anaesthetic risks involved in the event that such procedures are deemed necessary. I accept the responsibility for payment and agree to pay medical, transport and any other related expenses. I confirm that the information contained in this application is true and correct. I agree to inform the leader of any change to these details. Name and e-signature of Applicant: Date: Integrity Check Information PLEASE TICK - It is The Salvation Army policy that all volunteers must consent to undergo an integrity check. Criminal History Check (Police Check): * Yes No Working with Children Check: * Yes No If you already have a current Working with Children Check please upload a copy below. Copy of Working With Children Check: Working with Children Number: Expiry Date: References It is now Salvation Army Policy to make sure all volunteers have at least two character references before becoming a volunteer. Reference 1 Referee Name 1: * Contact Number: * Reference 1: Reference 2 Referee Name 2: * Contact Number: * Reference 2: Hoodie and Tshirt Size: * X Small Small Medium Large x Large xx Large xxx Large xxxx Large Thank you for completing the above details. The details on this form will be entered into our secure online Volunteer Management System. For details of how your information is secured please refer to The Salvation Army’s Privacy Notice included in the Volunteer Agreement Form or via our website, www.salvationarmy.org.au. Upload a Passport Photo: * * Required field The Salvation Army is committed to upholding the Australian Privacy Principles. Click here for more information
