Personal Information

*Title
*Last Name	*First Name
Middle Name	Preferred Name

*Street Address	*Suburb
*State	*Post Code
Telephone (Home)	Telephone (Work)
*Mobile	*Email Address
*Gender	*Date of Birth	[ 1/05/2024 ]

Emergency Contact Details

*Name		*Contact Number
Relationship		Relationship - Other

Other Information

Are you of Aboriginal or Torres Strait Islander descent?

*How did you hear about us?

*Do you speak/write in another language?

If Yes, Which Language?

If others, which Language ?

*Please advise us of your current employment status:		Other Employment Status

Do you have your own transport?		*If No, Are you comfortable navigating public transport?


The Community Visitor Scheme is committed to providing equal opportunities to all applicants and will select volunteers on the basis of merit for the volunteer position.

*Do you have lived experience with Mental Health or Disability ?

If yes, Which?

Do you have a medical condition that will affect your volunteer work?

If YES, how can we best support you?


You will be required to do a minimum of two visits every month, for up to 4 hours per visit. Please let us know what days of the week you are available. Please note that we will discuss how our scheduling process works with you as part of the recruitment process. (AM covers 9.00 am to 1.00 pm. PM covers 12.00 noon to 6.00 pm)


In order to assist us in considering your application, we request that you provide us with contact details of three referees who are able to attest to your skills relevant to the Community Visitor role.

Referees

(1) Name		Phone
Connection to You		Email

(2) Name		Phone
Connection to You		Email

(3) Name		Phone
Connection to You		Email

Please declare any potential conflict of interest (eg if you have worked, have friends or family at, or have been a client at an approved mental health facility or disability accomodation services. This will be discussed with you further as part of the recruitment process.


Please let us know why you are applying for the role of Community Visitor and what experience and / or qualifications you have that would assist you to perform in the role. (255 characters maximum)

Upload Resume Only

Please enter the details of valid Screening Checks you already hold

NDIS Worker Check Issue Date	[ 1/05/2024 ]
NDIS Worker Check ID
Working with Children Check Issue Date	[ 1/05/2024 ]
Working with Children Check ID
Aged Care Sector Employment Check Issue Date	[ 1/05/2024 ]
Aged Care Sector Employment Check ID
COVID-19 Vax Date	[ 1/05/2024 ]
Covid Vaccination Second Recent Date	[ 1/05/2024 ]
Covid Vaccination Third Recent Date	[ 1/05/2024 ]
Annual Influenza Vaccination season	[ 1/05/2024 ]

Declaration

I, declare that the information given in this application is true and correct.

I acknowledge that any false or misleading information may lead to my application being rejected or any subsequent approval revoked.
I consent to undertaking the Screening Checks deemed necessary by the Community Visitor Scheme.
I agree to receive all vaccinations required to perform the role.
I agree to undertake the relevant training required to carry out the role.
I agree to visit and inspect a range of services and facilities as required.
I will notify the Principal Community Visitor if any of my above circumstances change.
I acknowledge that this is an application only and appointment as a Community Visitor is subject to the needs of the Community Visitor Scheme.

Privacy Statement

The Community Visitor Scheme collects information on this form for the purpose of registering and assessing your interests in becoming a volunteer Community Visitor. Your personal information will not be disclosed to any external party without your consent, except where required or authorised by law.
The information you provide on this form will be entered into the Volunteer Information database.

Sun	Mon	Tue	Wed	Thu	Fri	Sat

COMMUNITY VISITOR SCHEME

Application to become a volunteer