Name* Surname First name Preferred name First DOB DD slash MM slash YYYY Address* Full address: street address, suburb, state, postcode Phone (home)Phone (mobile)Email Emergency Contact* Full name Relationship Telephone Mobile Relevant Medical Condition(s)(which may impact on your role as a volunteer.)Have you been fully vaccinated against COVID-19?*It is a mandatory requirement that all volunteers have had 2 does of the covid-19 vaccine and receive their booster dose (3rd) within 4 weeks of becoming eligible. Yes, I have had three doses of a COVID-19 vaccination. I have received two doses of a COVID-19 vaccination and am not yet eligible for my third dose. I intend to have my third dose within 4 weeks of becoming eligible. None of the above applies to my situation. Why are you interested in becoming a volunteer?Languages spoken(Languages other than English.)Do you hold a current Australian Drivers Licence?* Yes No *Please note an Australian Drivers licence is required to undertake our volunteering roles. If you do not hold an Australian Drivers licence, we will be unable to proceed with your registration. How did you hear about us? Tick the following services with which you would like to assistSocial Support Befriending Outings Telephone support Dog walking Transport assistanceTransport assistance Medical/Business appointments Home maintenanceHome maintenance Weeding Lawn mowing Are you able to transport equipment? (i.e mower, whipper snipper)Are you able to transport equipment? (i.e mower, whipper snipper) Yes No ShoppingShopping Accompanied shopping List shopping Availability(Select days you have availability, then specify the time you are available) Monday Tuesday Wednesday Thursday Friday Monday availability (Specify time available)Tuesday availability (Specify time available)Wednesday availability (Specify time available)Thursday availability (Specify time available)Friday availability (Specify time available)How often would you like to volunteer? Weekly Fortnightly Monthly How long would you like to volunteer for? 1-3 months 3-6 months 6-12 months Ongoing As part of my application as a volunteer I agree to the following conditions:* I agree.1. The Program Co-ordinator or other authorised Clarence City Council employee may contact my referees regarding my suitability as a volunteer for the program. I consent to arrange for a National Police Security and Criminal Record investigation and for that information to be provided to the Program Co-ordinator as part of my application. 2. To observe and carry out to the best of my ability, any directions from the Manager of Customer Services, the Program Co-ordinator and the requirements of the Volunteer Service program’s policies and procedures. 3. To observe the confidentiality of the clients of the program, of my fellow volunteers, program staff and of the Clarence City Council. I agree not to divulge or disseminate personal information of any client, without the consent of the client and Program Co-ordinator. 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 Council for the Volunteer Service. 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 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.