St John Ambulance Australia SA Inc. Membership Application Form (18+)

Transcription

1 Your Personal Details: Member Number (If previous member): Title: First Name: Surname: Middle Names: Preferred Name: Home Address: Suburb: Post Code: Postal Address (if different from above): Suburb: Post Code: Phone (home): Mobile: Address (required): Date of Birth (dd/mm/yyyy): Age: Occupation: Gender Male Female Do you have a current Driver s Licence? Y N Licence Number: Class: State of Issue: Years Held: Restrictions: Expiry Date: Are you able to drive yourself to events and your chosen division? Y N Do you have your own vehicle? Y N Are you of Aboriginal or Torres Strait Islander descent? Y N Do you have any cultural/religious beliefs that could have an effect on being a Volunteer? Y N If yes, please specify: Do you speak another language? Y N Please Specify: Are you currently in Australia on a VISA? Y N If YES what type of VISA is it? Date of Expiry: / / Please note any restrictions on your VISA (Bring the original Visa with you to your interview) In case of a personal emergency please notify: Title: Given Name: Surname: Relationship: Preferred Contact Number: Please tick which volunteer role you are applying for: Probationary Adult (First Aid Services) Probationary Adult (Non Operational) Cadet to Adult (First Aid Services) Cadet to Adult (Non Operational) 1 P a g e

2 Have you previously been associated with St John? If yes, please provide details: State: Branch: Years of Service: Grade in order: Last Role: Paid Voluntary Please state why you would like to become a St John Ambulance SA volunteer? Please provide details below, including expiry dates, if you currently hold a Provide First Aid Certificate or equivalent, or if you are a registered health practitioner with the Australian Health Practitioner Regulation Agency (AHPRA). Please provide us with two References (cannot be family members or partners) Given Name: Surname: Phone: Relationship: Give Name: Surname: Phone: Relationship: How did you hear about Volunteering with St John Ambulance SA? Word of mouth Advertising (if so, where) Brochure: TV Commercial St John SA Website Radio Internet (external site) Paper Advertisement Other (If other, please specify) Do you have a criminal history or have you ever been charged or subject to criminal proceedings in Australia or any other country? Y N If yes please provide evidence. 2 P a g e

3 Medical Questionnaire **Confidential** This document is for use by St John SA in assessment of an applicant s ability to undertake essential components of the Volunteer position being applied for. Title: First Name: Surname: Middle Names: Preferred Name In the past 5 years have you had or been diagnosed with any of the following: 1. A medical condition resulting being unable to or being instructed not to drive? Y N 2. High blood pressure, stroke or blood disorder e.g. Leukaemia or Haemophilia? Y N 3. Mental or nervous disorder e.g. stress, depression, lethargy, fainting, fits, seizures, blackouts, Y N epilepsy, paralysis, brain disorder or chronic fatigue syndrome? 4. Allergies (e.g. hay fever, food products, chemicals or medication)? Y N 5. Back pain, sciatica or other disorder of the back or spine including the neck (whiplash injury)? Y N 6. Health problem restrict your activities of daily living? Y N 7. Injury from a motor vehicle accident? Y N 8. Incurred a head injury, brain injury or concussion? Y N 9. Back, neck, shoulder, knee and hip conditions? Y N 10. Suffer from any condition that requires regular medical review or will require time away from Y N volunteering for treatment or rest? 11. A communicable diseases (e.g. hepatitis A, B, C, HIV/AIDS) or problem that may impair Y N your ability to be a volunteer or may affect other volunteers? IMPORTANT: If you have answered YES to any of the questions please give details below: Question Condition/Injury Time off work Recovery Degree (%) Full details of treatment including date of last symptoms Full name of doctor or hospital (if any) 3 P a g e

4 Medical Questionnaire Cont d.. **Confidential** 12. Would you or do you have difficulty with any of the following activities? a. Walking on rough / uneven ground? Y N b. Kneeling? Y N c. Combination of standing & walking for two (2) hours? Y N d. Concentrating on what you are doing? Y N e. Hearing a normal conversation? Y N f. Squatting? Y N g. Sitting for two (2) hours? Y N h. Lifting or bending? Y N i. Gripping firmly with both hands? Y N j. Reading ordinary print? Y N k. Repetitive movements of the hands or arms? Y N l. Understanding English? Y N m. Lifting 20 kilograms and walking a reasonable distance Y N with that weight? n. Performing 5 continuous minutes of effective one person adult CPR Y N IMPORTANT: If you have answered YES to any of the questions please give details below: Question Condition/Injury Time off work Recovery Degree (%) Full details of treatment including date of last symptoms Full name of doctor or hospital (if any) 4 P a g e

5 Medical Questionnaire Cont d.. **Confidential** Are you taking any prescribed or non-prescribed medication currently? If yes, please list below: Medication Treatment for: IMPORTANT: Please read and sign this section carefully to ensure you understand the conditions and requirements of St John SA. Declaration: I, (full name).., declare that the above answers are true and correct to the best of my knowledge and that I will, if required, reveal to my examining medical practitioner all circumstances known to me concerning my health and fitness that are relevant for appointment to the position for which I am applying. I acknowledge that the provision of incorrect information or the omission of any information regarding my health and fitness may result in the cancellation of my application or my dismissal from any position in St John Ambulance Australia SA Inc. I declare that I do not have an impairment that will detrimentally affect or is likely to affect my capacity to work as a St John Volunteer. Full Name: Date: Signature: If you need any further assistance with completing this form please contact the HR Volunteer Coordinator on or at volunteerservices@stjohnsa.com.au 5 P a g e

6 **IMPORTANT** CONSENT MUST BE COMPLETED I, the undersigned, make application for registration as a volunteer of St John Ambulance Australia SA Inc.(St John SA) and in so doing make the following declaration: disclosed to anyone not authorised to know that information. my registration as a volunteer will be kept confidential and not s, procedures and regulations of St John SA as defined and amended from time to time, as well as any instructions that may be issued by the National Office and/or State Office from time to time. I understand that St John SA is subject to Federal and State legislation in regard to Health, Safety, Discrimination, Harassment, Child Protection and Privacy and I must act in accordance with this legislation. I understand that St John Ambulance Australia is an equal-opportunity employer. SA Code of Conduct - Adults skills including child protection training so that the professional image of St John SA may be enhanced. I understand my obligations in presenting the best possible image of St John Ambulance Australia to the public and that I grant permission for St John SA to use my image for publicity and communication purpose. physical duties as outlined in Fitness Requirements. If at any time I am no longer able to do so, I will advise the appropriate officer at the earliest practical moment. SA of any physical or medical condition that could hinder me satisfactorily completing tasks that may be required as part of my work as a volunteer and that I have sufficient reading and writing ability to be able to satisfactorily complete tasks that involve the use of such ability. I will also notify St John SA immediately of my change of circumstance, including but not limited to the inability to drive a motor vehicle in the case of suspension or loss of driver s license. John SA. of St will commence volunteering with St John SA on a six (6) month probationary period, which in consultation may be extended. I understand my volunteering with St John SA may cease during my probation, with no right of appeal. onfirm I must maintain confidentiality whilst a member of St John SA. I also understand that my responsibilities regarding any confidential information that I had knowledge of whilst a member of St John SA is subject to the same conditions upon me if and when I am no longer a member of St John SA. SA to solicit a reference from my above nominated Referees in regards to my application to become a full member of the Operations Branch offer the Provide First Aid (PFA) training at a discount of 50% of the current rate of our PFA course to assist with membership application. I declare that all the information I have supplied in this application is true and correct and understand that any false declarations made above will invalidate my application. I understand that my acceptance as a volunteer will not be granted until all requirements have been met, including a National Police Certificate (NPC) and a probationary period. Full Name: Date: Signature: Thank you for your interest in becoming a St John SA Volunteer. Once your application form is completed, please send it to the address below: HR Volunteer Coordinator, St John Ambulance Australia SA, 85 Edmund Avenue. UNLEY SA 5061 Please direct any membership enquiries to the HR Volunteer Coordinator on or volunteerservices@stjohnsa.com.au 6 P a g e

7 Polo Shirt & Name Badge Order Form St John requires the following: Your given or chosen name for your name badge. NAME: Your Shirt Size for St John Polo Short Sleeve Top. Please tick your size: XS (6-8) S (10-12) M (14-16) L (18-20) XL (22-24) Other size please state: Once your membership requirements to St John SA - Operations Branch have been approved, a Welcome Pack will be given to you at your first day of training. Regional member s Welcome Pack will be sent to the chosen division. Welcome aboard and enjoy your journey volunteering with St John SA 7 P a g e

8 Approval The application for registration as a volunteer has been: Date Processed:.../.../... Authorising Officer:... Office Use Only Membership Application Form Received Date:.../.../... National Police Certificate Received: Date:.../.../... National Police Certificate Approved Date:.../.../... Qualification Evidence Received (if not a St John certificate, please provide an original certificate) Date:.../.../... Qualification Checked by: Date:.../.../... Interview Date:.../.../... Time: am/pm First Referee Report Received Date:.../.../... Second Referee Report Received Date:.../.../... Provide First Aid Course Approved Date:.../.../... Provide First Aid Course Attended Date:.../.../... New Member Induction Program Date:.../.../... Welcome Sent Date:.../.../... TASS Database Entry Created Date:.../.../... 8 P a g e