Office use only:

¨ PC ¨ RefC ¨ IDC ¨ N/Badge ¨ C/induction ¨ WWC ¨ DC

Today’s date
Surname
First Name
Preferred name
Date of Birth
Postal Address
Suburb and Postcode
Home #
Mobile #
Email
Emergency contact and telephone number
Relationship / o Spouse o Friend o Dr o Other
Skills you would like to offer as a volunteer:

Please tick

I will hold a current drivers license while volunteering / o agree
o don’t drive
The set up of my work area or tasks I do/will need to be considered for the following reasons;
/ o allergies
o existing health condition
o some mobility restrictions
o other practical support needs
o not applicable
Provide a brief description of your condition and/ or support needs
Are you an Australian citizen or permanent resident? / o no
o yes
If not, what passport do you hold?
Is your volunteering a part of a Centerlink program / o no
o yes
Your case worker’s name & tel. #
How did you hear about volunteering? / o local notice board poster
o word of mouth
o a community newspaper
o a council volunteer / staff person
o council website
o other
Availability please mark X when you are available / Positions of Interest:
Morning / Afternoon
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Photo Permission

v  I permit the City of Nedlands to use my photograph for the promotion of volunteering in the community. I am aware that due to bulk printing it may be used for several years. Yes / No

______

Office use only:

¨ mobile phone policy signature date:______

¨ IT policy signature date:______

Staff notes:______

______

______

______

______

Reference #1

Please provide your referees contact details

Full Name: ______

Tel: ______Mobile: ______

Office use only:

Staff to provide a description of the role the volunteer has registered for.

1. In what capacity do you know the applicant? ______

______

2. How long have you known the applicant? ______

3a. Would you consider them suitable for this type of position? Yes / No

3b. If no is there a reason your happy to share? ______

______

4. On a scale of 1 – 10 (10 being excellent)

Initiative ___Ability to follow direction ___Personal presentation ____

5. From your experience is the applicant reliable?

Never ¨ more often than not ¨ always ¨

Is there anything else you would like to add?

______

______

Staff Notes:

______

______

¨ Reference not required. Approved by ______

Reference #2

Please provide your referees contact details

Full Name: ______

Tel: ______Mobile: ______

Office use only:

Staff to provide a description of the role the volunteer has registered for.

1. In what capacity do you know the applicant? ______

______

2. How long have you known the applicant? ______

3a. Would you consider them suitable for this type of position? Yes / No

3b. If no is there a reason your happy to share? ______

______

4. On a scale of 1 – 10 (10 being excellent)

Initiative ___Ability to follow direction ___Personal presentation ____

5. From your experience is the applicant reliable?

Never ¨ more often than not ¨ always ¨

Is there anything else you would like to add?

______

______

Staff Notes:

______

______

¨ Reference not required. Approved by ______

TRIM #M12/28762 1/03/2013