Name* First name Last name Preferred name First Date of Birth* DD slash MM slash YYYY Address* Full address: street address, suburb, state, postcode Phone number*Email* Is your home address different to your mailing address? Yes No Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Do you speak any languages other than English? If yes, provide details: What are your preferred gender pronouns? She/her He/him They/them Other (please specify) Specify your preferred pronoun Emergency Contact 1 (primary)* Full name Relationship Contact Number Emergency Contact 2 (secondary)* Full name Relationship Contact Number Do you have a medical condition that may impact your ability to volunteer with us?* Yes No This could include a disability, an injury, or any other medical condition (including allergies). Please specify relevant Medical Condition(s)Are you taking any medication that may impact your ability to volunteer with us?* Yes No Please specify relevant medicationsWhy are you interested in volunteering with us?* To help others in the community/make a difference To build professional skills/experience To meet new people/expand connections To meet Centrelink requirements Other (please specify): Why are you interested in becoming a volunteer?What kind of volunteering would you like to do?* Select All Gardening (doing light mowing, weeding, or pruning for local residents) Transport (taking people to medical, business, or other appointments) Shopping (helping someone do their shopping or doing their shopping for them) Dog walking (walking someone’s dog) Phone support (providing support over the phone) Befriending (getting to know someone in the community and providing regular support) When are you available to volunteer? (please indicate Morning, Afternoon or all day)*MondayTuesdayWednesdayThursdayFridaySaturdaySunday What schedule of volunteering would best suit you?*WeeklyFortnighltyMonthlyAd hoc/as neededHow long would you like to volunteer for?*1-3 months3-6 months6-12 monthsOngoingAdditional information*YesNoDo you have a current Australian driver’s licence?Since turning 16, have you been a citizen or permanent resident of a country other than Australia?Have you been vaccinated against Covid-19?Do you have a current Working with Vulnerable People check?Have you completed a National Police Check in the past 3 months?Do you have a current First Aid certificate?RefereesReferees Please provide the details of at least one referee who can speak to your character, experience, or ability to complete volunteer work with us. This does not have to be a manager or supervisor, but could be a friend or someone you know through the community. Please note that referees from family members will not be accepted. Referee 1 (required)*First nameLast nameRelationshipContact number Referee 2 (optional)First nameLast nameRelationshipContact number How did you find out about our volunteer program?* Word of mouth Internet search Jobs website (Seek, Indeed etc) Social Media Newspaper Poster, flyer or brochure Council staff Other (please specify) Other (please specify) Anything else you’d like us to know?As part of my application as a volunteer I agree to the following conditions:* I agree.1) I consent to arrange a National Police Check and for the results of this check to be shared with the staff at Clarence Community Volunteer Service. 2) I consent from a staff member or other representative from Clarence Community Volunteer Service to contact my referees to assess my suitability for this program. 3) I will observe and carry out, to the best of my ability, any reasonable instructions from Clarence Community Volunteer Service staff, as well as follow, to the best of my ability, Clarence Community Volunteer Service policies and procedures. 4) I will observe the confidentiality of everyone in the program, including clients, volunteers, and staff members. I agree not to divulge or disseminate personal information of any client, without the consent of the client and program leader. Privacy Statement* I consent to the collection and use of this information by Clarence City Council.The personal information on this form is required by Clarence Community Volunteer Service on behalf of Clarence City Council. We will only use your personal information for this and directly related purposes, or as required by law. If this information is not provided, we may not be able to offer you a volunteer position. You may access and/or amend your personal information at any time. How we use this information is explained in our privacy policy, which is available at www.ccc.tas.gov.au or at council offices. I consent to the collection and use of this information by Clarence City Council.