Volunteer Application Form: Long Version

Volunteer Application Form
Personal Details
Title*
Name*

First NameLast Name
Preferred name*

First NameLast Name
Address*

Street Address

Street Address Line 2

Suburb State

Postcode
No fixed address
Birth Date*

DayMonthYear
Gender*
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Mobile number*
Email*
Employment status*

Working FTWorking PT/ CasualRetiredUnemployedOther
Main language spoken
Other languages
Do you identify as Aboriginal or Torres Strait Islander?*
Country of birth*
Main language/s spoken at home *
Do you have any health issues or disabilities which may affect you or prevent you from performing particular types of volunteer activities?*
If you answered yes in the previous question, please provide more info below:
How did you hear about South Eastern Community Connect (SECC)?*

A family memberA friendThe SECC websiteWalking past The SECC Hub on Botany RdA SECC email newsletterA SECC printed newsletterA Facebook postAn Instagram postA flyer/brochureA poster on a noticeboardOther
Why would you like to volunteer with SECC?*
Volunteer experience
Have you ever volunteered before? If yes, please list the one or two most recent organisations here:
Please describe the type of work you did in your previous role/s:
How long were you there?
Which volunteer activities are you interested in?*

Children's Activities AssistantTutorSocial Activities Assistant (Dementia Day Centre in Darling Point)Driver for the Flexible Respite Transport ServiceMedical CompanionMarketing and Social Media AssistantGraphic DesignerVideographer or Video EditorJournalistOther
Do you have experience in a field, or specific skills you'd like to share? e.g. education, IT, gardening, arts and crafts
When are you available?*

Mon AMMon PMTue AMTue PMWed AMWed PMThu AMThu PMFri AMFri PM
How often are you available?*

FlexibleDailyWeeklyFortnightlyOther
Number of hours per week you would ideally like to volunteer?*
Driving Details

* Only required for volunteer drivers
Do you have a driver's licence?

YesNo
If yes, how many years have you been driving?
Do you have your own car?

YesNo
Licence type/s held

LearnersProvisional (P1)Provisional (P2)Full Licence
Class(es) of licence held

CarRiderLight RigidMedium RigidHeavy RigidHeavy CombinationMulti Combination
Emergency Contact
Their name*
Their relationship to you*
Their mobile number*
Referee
Name*
Daytime contact number*
Relationship to you*
Medical Conditions
Do you have a disability, impairment or condition that may preclude you from carrying out some of the volunteer roles? Tick all that apply.*

Intellectual/learningPsychiatricSensory/speechPhysical/diverseN/A
If yes, please specify:
Multimedia Consent
South Eastern Community Connect (SECC) may take photography, audio, and video recording throughout the duration of its programs and activities for multimedia content production which is typically used in organisational promotion and marketing in a range of platforms and mediums. Do you provide multimedia consent?
No, I do not provide multimedia consentYes, I, as named above, consent to South Eastern Community connect and its agents (including without limitation, any photographer, interviewer, creative agency or media organisation) recording images of me during SECC events, programs and activities for promotional purposes. I consent to these images being used and disclosed to any person or organisation approved by South Eastern Community Connect, including without limitation, by publishing them as part of a book, poster, brochure or report, newspaper advertisement or article television advertisement or program, radio advertisement or program and including on the world wide web or any other social media. I agree that South Easter Community Connect and its agents may edit the images prior to publication, as they consider appropriate, without first consulting me.
Privacy and Confidentiality Policy:
SECC has a strict policy around issues of privacy and confidentiality. All files are securely maintained.Your name and personal details will not be given to any person or agency outside of the Centre without your informed and voluntary consent. Exceptions to this agreement involve:
- Where a child or young person under the age of 16 years is at risk of significant harm from abuse or neglect (e.g. a child or young person witnessing incidents of Domestic Violence)
- Where there is a serious and imminent threat to life and health of any person, including the person seeking a service (e.g. a person is at risk of hurting themselves or harming others)
- Where a person discloses information that would substantially assist in the prosecution of any offence punishable by 5 or moreyears imprisonment
- Where a worker is required to provide documents (e.g. a person's file) or give evidence under subpoena
All SECC staff can descrive these exceptions in more detail if you have any questions please make sure to ask.
Data Collection
SECC collects basic program statistics. The collection is for funding and reporting purposes. The collection never identifies individuals. The collection allows us to monitor service usage patterns across the years. It also allows us to report to our Board and the bodies that provide us with funding with service provision. At no stage is any identifying data provided to either the Board of SECC or to funding bodies. If you choose to not have this particular information passed on you are able to inform the worker. You will still be able to receive services from SECC. Do you consent to the collection of statistics for the purposes stated above on the condition that any collection will not identify you personally?
YesNo
Would you like to receive information about upcoming events and programs?*
Agreement and Acceptance

I understand and agree that:
• The work undertaken by South Eastern Community Connect (SECC) and the business of service users (clients) is strictly confidential and I will maintain and respect SECC and service user confidentiality at all times.
• SECC works with frail aged and younger people with disabilities and their carers, and we must ensure their safety at all times.
• I give permission for the referee specified above to be contacted.
• A Police Check will be undertaken and a Working with Children Check will be undertaken for work involving children.
• A NSW Licence Check will be undertaken for Volunteer Drivers
Signature

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Volunteer Application Form

Personal Details

Volunteer experience

Driving Details

Emergency Contact

Referee

Medical Conditions

Multimedia Consent

Privacy and Confidentiality Policy:

Data Collection

Agreement and Acceptance