Volunteer Recruitment Form Step 1 of 6 16% 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. Note: You will need to also complete a Statutory Declaration and a Disability Worker Exclusion Scheme (DWES) declaration and sign a Position Description and Code of Conduct document. The documents with information and instructions for completion are available on the Volunteer Hub. PART A – Personal detailsTitleFirst Name*Last Name*Address* Street Address Suburb Post Code Name of your local CouncilEmail Address* Home PhoneMobileBusDo you identify as Aboriginal or Torres Strait Islander?*YesNoHave you lived overseas the last since the age of 16?*YesNoPlease 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)RelationshipHome PhoneMobileBus **PART C – Student Course Details (only for students completing placement / internship) Click "Next" at the bottom of this page if this does not apply to youSchool / FacilityCourse NameCourse ContactContact’s Phone noEmail Address Hours to CompleteDescription of Placement / Specific Support Requirements Part D – Volunteer role information The answers to the following questions will provide us with a starting point as to what skills and expertise you bring with you, and how you could be of greatest help to Inclusion Melbourne:1. What type of volunteer work would you like to do with Inclusion Melbourne? (Please tick box/es)*Leisure BuddyTutorOffice/Project WorkCommunity Visitor2. What times are you available to volunteer:Please indicate AM/PM/eveningMonTuesWedThursFriSatSun3. Please provide two professional/work related referees:Name of referee (1)RelationshipEmail address Phone numbersName of referee (2)RelationshipEmail address Phone numbers4. Have you ever done volunteer work before, including at Inclusion Melbourne?YesNoWhere 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?YesNoDetails of your experience:5. Please provide us with a summary of your background experience, skills and any qualificationsCurrent OccupationWork experience (paid or voluntary)QualificationsSkillsLanguages (please state level of competence)Interests, hobbies6. **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,C and D on this form is true and correct. PART E – Disclosure of Previous Injury In accordance with the Accident Compensation Act 1985 (Vic) and successor legislation you are required to disclose any or all pre-existing injuries, illnesses or diseases/ conditions (pre-existing conditions) suffered by you which could be accelerated, exacerbated, aggravated or caused to recur or deteriora Please note that, if you fail to disclose this information or if you provide false and misleading information in relation to this issue, you may not be entitled to any form of workers’ compensation. Please also note that the giving of false information in relation to your application for employment with Inclusion Melbourne may constitute grounds for disciplinary action or dismissal.Are you required to take regular medication which may:Affect Work Performance?*YesNoPlease Specify:*Affect your attendance at work?*YesNoPlease Specify:*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 employment.Yes, I have pre-existing injuries or diseases that might be affected by the nature of the proposed employment.Please list details of all pre-existing conditions:*Provide details of management strategies and/or medication for existing conditions / allergiesPlease give details of any Work Cover claims made in the last five years:Declaration* I certify that the information provided in Part E is true and correct and that I have read the position description and understand the nature of the tasks that I am required to perform Part F – Publications 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.Please tick appropriate box:*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.Note, you may may decide to withdraw your consent at any time by contacting Inclusion Melbourne **PART G – 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?YesNoLicence Type*FullProbationaryLicence No:*Conditions*Expiry date:*Vehicle DetailsVehicle type/model:Registration No:*Vehicle is Roadworthy*YesNoVehicle is Registered*YesNoInsurance Details name/company:Type of Insurance: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.