Membership Form - Community Drug Action Team (CDAT)

Membership Form – CDAT 2

Membership Form - Community Drug Action Team (CDAT)

Document Version Control

Ref No. / Created by / First Adopted / Last Modified / Modified By / Review Period
Doc No 13 / H. Hodgson (ADF, SCDO) / 31.07.2015 / 22/04/16 / H. Hodgson (ADF, SCDO) / Twelve months

The following form is a contact sheet for the purpose of the Australian Drug Foundation’s (ADF’s) Senior Community Development Officers (SCDO’s). It is to also ensure the ADF have the most current and up to date contacts for each CDAT.

CDAT
Member Details
First Name / Surname Name
Organisation
Mobile / Home Phone
Work Phone / Fax
Email Address
Postal Address / Post code
What brought you to CDAT? E.g. my job, personal interest, sporting club etc.
How would you like to be involved? E.g. Committee role, events, membership promotion, media liaison etc.
Have you held any positions on the CDAT executive? Please note that each position should not be held by the same person for more than three consecutive years unless supported by 75% of the CDAT
What is your primary occupation? E.g. community member, Drug & Alcohol sector, Aboriginal services etc.
Do you have any other community volunteer roles? E.g. Lions, Rotary, sporting club etc.
If so, please name below:
I have particular interest in:
☐Illegal Drugs
☐Legal Drugs
☐Mental Health
☐Suicide prevention
☐Alcohol
☐Wellbeing events
☐Conference & Forums
☐Training
☐Diversionary projects
☐Other (please name)
Skills Audit

This audit aims to facilitate collaboration and sharing of knowledge for the benefit of CDAT. The information provided will be maintained by the Senior Community Development Officer and will be used to benefit the CDAT and will not be shared with a third party without your permission. Please list any other skills or interests you may have eg art, music, accounting, media, advertising, grant writing, fundraising etc.

Additional information? If you have any additional information/comments specific to your CDAT that you wish to advise of, please write here:
Photo and Image Consent Form

Photography and image consent for______Community Drug Action Team (CDAT), the Australian Drug Foundation and NSW Ministry of Health. CDAT sometimes takes photographs of its activities for local publicity purposes.

The Australian Drug Foundation, which supports CDATs and their events, often obtains photos from CDATs to use in a variety of promotional publications, print and electronic media eg both the website and newsletter contain photographs of community activities etc. The website and newsletter are tools to profile community activities and events relating to harm minimisation for drugs and alcohol.

This form authorises the above named CDAT, Australian Drug Foundation and NSW the Ministry of Health to use photographs taken at community drug action programs and events to be used for various publicity purposes, including on the Community Drug Strategies website and/or in the Drug Action newsletter.

Name of photographed person: ______

☐ I give permission for photos and images of me to be used. ☐ I do not give permission for photos and images of me to be used.

Membership Agreement

☐I accept the Terms of Reference of the ______CDAT.

☐I agree to work within the Framework for Action. http://adf.org.au/images/stories/CEAP/ADF_CEAP_Framework_2015.pdf

☐I understand and give permission for the information I have provided to be used by ______CDAT. I understand that the information I have provided is confidential and this information will not be used for any purpose other than CDAT related activities.

☐I give permission for you to disclose my contact and skills information to other CDAT members for the purpose of CDAT business and activities.

Signature: ______Date: ______