On-line Volunteer Application Form Volunteering Application Form All information provided in this form will only be used for volunteer management purposes, and will be treated in the strictest confidence. Title*Mrs, Ms, Miss, Mr Surname* Given Names* Date of Birth* Postal Address* Town or Suburb* Postcode* Phone Number*Your best phone number for contact Mobile Number* Email*Your best email for contact Drivers’ Licence Number* Expiry Date*Drivers’ licence expiry date Driving offences or accidents and year (if known):*Car type currently being driven:* General condition of car:* Excellent Good Poor I would be happy to transport Blind Welfare Association (BWA) members in my my own vehicle a BWA vehicle Please indicate your skills, hobbies, interests, and any qualifications.*Please specify type, date obtained, and learning institutionPrevious volunteer experience: please give specific details*Please indicate prefered volunteer program or type of assignment* Reading/Correspondence Driving Social/Recreational Activities Home Visits Gardening Fundraising/Special Projects Shopping Administration/Lotteries Number of volunteer hours prefered Which days of the week do you prefer to volunteer?* Monday Tuesday Wednesday Thursday Friday Saturday Sunday What part of the day would you like to volunteer ?* During the day At night Either day or night How often would you like to volunteer* Daily Weekly Fortnightly Monthly On Call Where did you hear about the Blind Welfare Association?* Family Someone who works at BWA Newspaper Radio Someone who lives at BWA I live locally Through Volunteering SA Through Study Please indicate your reasons for volunteering :*What do you feel you have to offer?*Please indicate any other languages other than English that you can speak:* Full name of reference 1*Please give details of 2 references to support your application: Address of reference 1* Phone number of reference 1* Full name of reference 2* Address of reference 2* Phone number of reference 2* Name of emergency contact*Please provide details for an emergency contact Phone number of emergency contact* Relationship of emergency contact* Please give details of any medical conditions*It is necessary for us to maintain a brief medical history of our volunteersDo you have ambulance cover?*Costs for any required ambulance are the responsibility of the volunteer Yes No Do you have any active or outstanding Workers Compensation Claims?* Yes No STATEMENT OF AGREEMENT*I certify that to the best of my knowledge, the above details are true and complete. I understand and agree to abide by the policies and procedures of BWA. I agree to follow direction given in relation to the safe performance of tasks and to undertake tasks in a way that does not endanger my own safety or the safety of others. Whilst acting as a Volunteer, I understand that I am covered by BWA’s insurance policy, subject to the terms of the policy, (as detailed in the BWA Policy and Procedure Manual). Whilst acting as a Volunteer I understand that I must follow reasonable direction in regard to Occupational Health and Safety as set down under the Work, Health and Safety Act and BWA policy. I understand that it is my obligation and responsibility to Blind Welfare, its Members and staff, not to disclose any confidential information obtained in the course of duty. I understand that BWA reserves the right to terminate my services as a Volunteer through appropriate process. I understand that BWA will conduct two Screenings through the Department of Community and Social Inclusion (DCSI), covering Aged Care Employment and Disability Services Employment as part of this application.Failure to disclose any relevant information (including medical conditions), which may impact on your role as a Volunteer may result in the termination of your Volunteer services with BWA. I give permission for my photograph to be used for publications to promote BWA eg our website. I have read and understand the BWA STATEMENT OF AGREEMENT Once you submit your form by using the button below you should be presented with a conformation page. If you are not presented with a conformation page their is an error in your form. Errors will be highlighted.EmailThis field is for validation purposes and should be left unchanged.