VOLUNTEER PEER EDUCATOR APPLICATION FORM

To help ensure that the skills of all our volunteers are recognised, valued and used effectively, please answer the following questions:

How did you find this advertisement?

Your age group: 50 – 60  61 – 70 71 – 75 75+ 

Your name:

Address:

Telephone:Mobile:

Email:

Please tick the box if applicable:

Do you enjoy working with groups of older people?

Do you enjoy working with people from Culturally and Linguistically Diverse backgrounds?

Do you feel confident or comfortable in presenting to groups of older people from your own community?

Do you feel confident or comfortable in presenting to groups of older people from other communities?

Are you able to respect older people from a different religious, cultural or ethnic backgrounds?

 Do you have an interest in the health issues, in particular among older people?

Are you willing to undertake training on health or anyother issues when appropriate?

Would you be able to travel a bit further to present to a group if requested by HPSOP? (HPSOP may sometimes request this if there is no Volunteer in that local area.)

Are you willing to set up an information stall at community events? (A few community events occur throughout the year.)

Could you describe briefly your qualifications and work experiences?

Do you have involvement with any community organisations? If yes, which organisation(s), position(s) and involvement?

Can you communicate in a language other than English and, if so, what language(s)?

Do you drive in NSW? Do you have a car? (A car is not necessary.)

Do you agree to undergo the National Police History Check”

(HPSOP will organise this with no cost to Volunteer Peer Educators.)

Could you please tell us why you applied for this volunteering position?

Please circle the days you would be able to work with us.

(Please note that, volunteering in HPSOP is a very flexible job which will not affect to other commitments you may have.)

Monday / Tuesday / Wednesday / Thursday / Friday

Please provide two referees:

1. Name & phone:

2. Name & phone:

Your signature & date

(Please note that, all Volunteers must abide by CPSA-HPSOP Code of Conduct for Volunteer Peer Educators)

Health Promotion Service for Older People (HPSOP) Level 3, 17-21 Macquarie St, Parramatta, NSW 2150

Phone: (02) 9281 3588 Country callers: 1800 451 488 Fax: (02) 9211 8700 Email: Web: ABN: 11 244 559 772

Auspice:Combined Pensioners & Superannuants Association of NSW Inc.

Funded by: South Eastern Sydney Local Health District

Updated: September 2017 Page 1 of 4