Volunteer Application Form Step 1 of 5 20% Thank you for your expression of interest to become a volunteer with Inclusion Melbourne. To take the next step, we require the following detailed information as part of our recruitment process. You can be assured that the privacy of your information provided is protected in line with privacy legislation and Inclusion Melbourne’s policy and procedures. PART A – Personal detailsTitle First Name* Last Name* Date of Birth* DD slash MM slash YYYY Address* Street Address Suburb Post Code Name of your local Council Email Address* Home PhoneMobileBusDo you identify as Aboriginal or Torres Strait Islander?* Yes No Have you lived overseas at any time since the age of 16?*If you answered yes, you are required to complete a Statutory Declaration form. See instructions on the form accessible from the Volunteer Hub. Yes No Please provide details of where you lived prior* PART B - Emergency Contact Details (for use in the event of illness or accident)Name (1)* Relationship* Home PhoneMobileBusName (2) Relationship Home PhoneMobileBus Part C – Volunteer role information 1. What type of volunteer work would you like to do with Inclusion Melbourne? (Please tick box/es)* Leisure Buddy Tutor Office/Project Work Community Visitor 2. What times are you available to volunteer:Monday AM PM Evening Tuesday AM PM Evening Wednesday AM PM Evening Thursday AM PM Evening Friday AM PM Evening Saturday AM PM Evening Sunday AM PM Evening I can be flexible with these times 3. Please provide two professional/work related referees:Name of referee (1) Relationship Email address Phone numbers Name of referee (2) Relationship Email address Phone numbers 4. Have you ever done volunteer work before, including at Inclusion Melbourne? Yes No Where have you volunteered? What type of volunteer work did you do?Have you had any experience supporting people who have a disability or elderly clients? Yes No Details of your experience:5. Please provide us with a summary of your background experience, skills and any qualificationsCurrent Occupation*Work experience (paid or voluntary)*Qualifications*Skills*Languages (please state level of competence)*Interests, hobbies*6. **Additional information about your interests (to be completed by Leisure Buddies only)6.1 Team Sport ActivitiesPlease tick all that applyI take part in…I like to watch...I'm not interested in...SoccerRugbyAFLCricketNetballTennisBasketballPlease indicate the teams that you support or any other team sports that you are interested in:6.2 Individual Sport ActivitiesPlease tick all that applyLikeNeither like nor dislikeDislikeSwimmingWalkingRunningYogaBowlingGo CartingMini GolfGoing to the GymAny other individual sports activity (please state)6.3 Places you like to visitPlease tick all that applyInterested/ like to visitNeither like nor dislikeUninterested/ prefer not to visitHistoric BuildingsMuseumsGalleriesGardensBeachesWildlife parks/ zoosMarketsAny other places or other info (e.g. specific places of interest)6.4 Leisure InterestsPlease tick all that applyInterested/ like to visitNeither like nor dislikeUninterested/ prefer not to visitMusic/ConcertsSingingDancingDrama/TheatreArts/Craft/ PotterySewing/embroideryAnimals/petsBoard GamesArcade gamesGardeningEating outGoing to the cinemaShoppingAny other interests or other info (e.g. groups you’re part of, lessons taken, etc.)Declaration* I certify that the information provided in part A, B and C on this form is true and correct. PART D – Disclosure of a medical issue As a duty of care requirement, please advise of any pre-existing health issue that may impact your ability to undertake tasks when volunteering.Do you have any knowledge of a pre-existing medical condition or injury?* No, I do not have any pre-existing injuries or diseases that might be affected by the nature of the proposed volunteer role. Yes, I have the following pre-existing injuries or diseases that might be affected by the nature of the proposed volunteer role. Please list details of all pre-existing conditions:*Provide details of management strategies and/or medication for existing conditions / allergies:*Declaration* I certify that the information provided in Part D is true and correct and that I am able to perform the tasks documented in the Volunteer Position Description. Part E – Publications consent & Information sharing consent From time to time, Inclusion Melbourne may take photographs and make records of events to create printed materials and/or Internet posts that are used for promotional or educational purposes. For CVS volunteers, their details may be shared with the Dept. of Health in matters relating to this service.Please tick appropriate box: Publications consent* I give consent for my image, likeness or representation to be used for internal and external purposes by Includion Melbourne, including photograps, film footage, audio material, publications, quotations and events. I do not give consent for the use of my image, likeness or representation by Inclusion Melbourne, including photographs, film footage, audio material, publications, quotations and events. Please tick appropriate box: Information sharing consent* I give consent for my name and contact details to be shared with the Dept. of Health. I do not give consent for my name and contact details to be shared with the Dept. of Health. Note, you may decide to withdraw your consent at any time by contacting Inclusion Melbourne **PART F – Driver Declaration (only for volunteers who will use their personal vehicle when volunteering)Driver DetailsWill you be using your personal vehicle when volunteering and if so, is your licence valid? Yes No Licence Type* Full Probationary Licence No:* Conditions* Expiry date:* Vehicle DetailsVehicle type/model: Registration No:* Vehicle is Roadworthy* Yes No Vehicle is Registered* Yes No Insurance Details name/company: Type of Insurance: Please read the Transport & Vehicles policy before ticking the Declaration Declaration* I confirm that I have read and understand the Transport & Vehicles policy located on the Volunteer Hub.I give authority for the use of my vehicle for conducting Inclusion Melbourne business and confirm that I am the only driver for these purposes. I acknowledge that: • at all times whilst driving my vehicle for conducting Inclusion Melbourne business I will adhere to the requirements of the Transport & Vehicles policy; • the information provided on this form is correct; • my vehicle is safe, in a roadworthy condition and the vehicle interior is clean; • my vehicle is registered and insured against legal liability for damage caused by my vehincle to the property of other people • any changes to my circumstances that affect driver authorisation and competency I must disclose immediately to Inclusion Melbourne.EmailThis field is for validation purposes and should be left unchanged.