InclusionPlus
FamilySupportInc.
QualitySupportInclusionForEveryone
5 Daniel Street, Nambour QLD 4560 Phone: (07) 5441 6600
SUPPORT WORKER APPLICATION FORM
Please Note: On receipt of this Application your name will be placed on a waiting list. We cannot guarantee when a position for which you are suited may become available.
You must hold a current Blue Card, First Aid and CPR certificate before your application will be considered.
Date of Application: ......
Name:Street Address:
Suburb:Postcode: / Phone:
Postal Address:
Suburb:Postcode: / Mobile:
Email: / Please confirm you are over 18: Yes No
Emergency Contact Name:
Emergency Contact Number:
CURRENT EMPLOYMENT: / DATES OF EMPLOYMENT:
- ......
- ......
PREVIOUS EMPLOYMENT:
- ......
- ......
REFERENCES: Please supply the names and contact numbers of four (4) work related referees. At least two (2) of these referees must come from Australian business organisations.
Please do not include co-workers; referees are to be supervisors only.
Please ensure your referees know we are contacting them.
No. / Name / Organisation/Agency / Position / Contact Phone No.1.
2,
3.
4.
Office Use Only:
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QUALIFICATIONS AND TRAINING
EXPERIENCE WITH CHILDREN/TEENAGER’S WITH A DISABILITY:
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EXPERIENCE WITH CHILDREN/TEENAGER’S WITH CHALLENGING BEHAVIOURS:
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Qualification/Training Typei.e. Certificate IV Disability / Lifting Training etc. / Training Provider / Date Completed
Compulsory Requirement / Expiry Date
Senior First Aid Certificate
CPR
Positive Notice Card (Blue Card)
Disability Services Positive Notice Card (Yellow Card)
Recently arrived overseas applicants will be expected to produce a Police Clearance Certificate
GENERAL INFORMATION
TYPE OF CARE YOU CAN OFFERVacation Care (6-12 yrs) / Yes/No / Teen Holiday Program (13-18 yrs) / Yes/No
After School Care / Yes/No / Pandanus Guest House (Centre Based Respite) / Yes/No
Recreation Days / Yes/No / Voluntary Care / Yes/No
Respite in your home / Yes/No / Respite in the Family’s Home / Yes/No
AVAILABILITY
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TRANSPORT
Are you prepared to transport children/teenagers?Yes / No
(If yes – annual car safety check is mandatory)
Type of Car:...... Year of Manufacture: ......
Registration Expiry Date: ...... Seating: ......
Insurance Company: ...... Type of Coverage: Third Party / Full Comprehensive
DRIVERS LICENCE No: ...... EXPIRY DATE: ......
Injury/Illness I have / I have not had any previous injury or illness including back or neck injuries in the past that would affect my ability to care for or lift children.Signed: ...... Dated: ......
Do you have any condition that could impair your ability to support a person with a disability?
i.e. Hearing, Vision, Diabetes, Epilepsy, Literacy.
......
SMOKING:
When employed by Inclusion Plus, you must not smoke in the presence of any person you are supporting.
NAMES AND AGES OF OTHER PEOPLE LIVING IN YOUR HOUSE
(Only to be completed if you have applied to provide respite in your home)
Please note – all people over the age of 18 years must have a Positive Notice Card (Blue Card).
Name / Age / Relationship to Applicant......
If any of the above persons are required to hold a Positive Notice Card (Blue Card) please indicate below:
Name / Current Suitability Card / Date Expires...... Yes / No......
...... Yes / No......
...... Yes / No......
Please sign this application to confirm that all the information you have provided herein is true and correct.
Signed by the Applicant:...... Date: ......
Interview Conducted by:
Name of Inclusion Plus Family Support Inc. Coordinator: ......
Signature of Coordinator: ...... Date: ......
Inclusion Plus Family Support Inc. is an Equal Opportunity Employer
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ABN 38 025 337 535 Fax: (07) 5441 3600 Email: Web:
Funded by the Queensland Government's Department of Communities, Child Safety andDisability Services
the following Australian Government Departments:
Families, Housing, Community Services & Indigenous Affairs; Education, Employment and Workplace Relations