Volunteer Registration Form - PDF

							                                 Volunteer Registration Form
                NSW Outreach (SOS) and Treatment (CAFSS) Courses


Date of application:____________________                                  Please print clearly
Title (Circle): Mr. - Mrs. - Miss - Ms - Dr - Other (please specify) ______________________
Name: ___________________________________________________________________________

Street address: _____________________________________________________________________

_______________________________________________________ Postcode: _________________

Mailing address (if different): ________________________________________________________

_______________________________________________________ Postcode: _________________

Telephone: (h) ________________ (w) _________________ (mobile)________________________
Email: ____________________________________________ Date of birth: ___________________
Drivers License No: ________________________ Type: ____________ Class: _______________
Expiry Date: ____________________
Emergency Information:
Special Medical Information (if applicable): ______________________________________________
Emergency contact: ________________________________ or ______________________________
Contact Telephone: ________________________________ or ______________________________

Enrolment type: Treatment Training Course Outreach Training Course Dual (Treatment & SOS)
(please tick)    Statement of Attendance          Statement of Attendance Statement of Attendance
                     5 days - $75                      3 days - $75                 6 days - $120
                         (Note that SOS course costs includes the use of a t-shirt)
Course start date: ___________________________ Location: ______________________________
Payment by (circle): Cash - Cheque - Master Card - Visa - Amex
Cardholder name: _________________________________________________________________
Card number: ___________________________________________ Amount: _________________
Signature: ______________________________________________ Expiry date: ______________



                                                      Office Use Only
  Permission for use of name         Permission for use of image            Receipt sent              DNS
  Entered in DONMAN                Receiving mail from DRUG ARM: Yes / No
Notes:


                                               DRUG ARM AUSTRALASIA
                     1/14 COURT ROAD FAIRFIELD NSW 2165 PO BOX 1030 Ph: (02) 9755 0596 Fax: (02) 9755 0593
                                                  ABN 64 102 943 304
HR-006/2                                                       Issue: 2                                      4/01/2010
                                 Volunteer Registration Form
                                                           (Please print clearly)




Privacy issues:
The personal information you provide to DRUG ARM is kept securely. You may ask to view the
information DRUG ARM holds about you at any time. To enable rostering changes and easier
running of programs, your program coordinator may need to provide telephone / email contact details to
other volunteers within the program.
Please indicate which details you authorise DRUG ARM to share with other volunteers within your
program.
           Yes, you may share my contact details with other volunteers within the program.
           My preferred contact number(s): _________________________________________________
           No, do not share my contact details with other volunteers
Are you willing to receive mail from DRUG ARM?                                                Yes            No
Are you willing for your name/photograph to be used in DRUGARM publications?
(e.g. Hands On newsletter) (strike out above if applicable)          Yes                                     No


Personal history:
Have you ever been (formally or informally) charged or disciplined for any child abuse, sexual abuse or
any drug related or criminal offence?
                                                                            Yes              No
Please specify: _____________________________________________________________________

Do you agree to provide your name to police for a criminal check?                             Yes            No

DRUG ARM’s policy on personal drug use applies to staff, volunteers and students: all are required to
be two years clear of any use of illicit substances, and two years clear of any addictive episodes
involving alcohol or prescription medications.
Can you comply with this policy?                                                              Yes            No

Work in the Alcohol and Other Drug field is emotionally and mentally challenging. Those with recent
episodes of mental or physical ill-health must discuss their situation with the Program Coordinator.
Do you need to book a meeting with the Coordinator?                                           Yes            No


Declaration:
I hereby certify that the above information is true and correct to the best of my knowledge.
Name:             ________________________________________
                              (Please print)
Signature:        ________________________________________
Date:             ____________________

                                               DRUG ARM AUSTRALASIA
                     1/14 COURT ROAD FAIRFIELD NSW 2165 PO BOX 1030 Ph: (02) 9755 0596 Fax: (02) 9755 0593
                                                  ABN 64 102 943 304
HR-006/2                                                       Issue: 2                                       4/01/2010
                               Volunteer Registration Form
                                                        (Please print clearly)



Educational Qualifications/ Institution/ Year: __________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Employer: ________________________________________________________________________
Position: __________________________________________________________________________
Voluntary Experience: _______________________________________________________________
__________________________________________________________________________________
Skills and Interests:
Languages spoken other than English: __________________________________________________
Fundraising Experience: _____________________________________________________________
Research Experience: ________________________________________________________________
Administration Skills: _______________________________________________________________
Other: ____________________________________________________________________________


How did you hear about the volunteering opportunities at DRUG ARM? _______________________
__________________________________________________________________________________


Please note that your suitability for volunteering with DRUG ARM will be assessed during
the training process. Completion of training does not guarantee a volunteer position with
DRUG ARM.
                                       ***************************

Selected Program/s:
(please tick)
CAFSS operates during business hours only                   Western Sydney


SOS operates in the evenings only                           Newcastle
                                                            Western Sydney
                                                            Sutherland
                                                            Wollongong




                                            DRUG ARM AUSTRALASIA
                  1/14 COURT ROAD FAIRFIELD NSW 2165 PO BOX 1030 Ph: (02) 9755 0596 Fax: (02) 9755 0593
                                               ABN 64 102 943 304
HR-006/2                                                    Issue: 2                                      4/01/2010
                               Volunteer Registration Form

Availability for NSW volunteers:

(please tick relevant boxes)             indicates that the program does not currently operate on this day
                          Mon        Tues      Wed       Thurs         Fri    Sat      Sun
 CAFSS Western
 Sydney Business Hours
 SOS Evening

How often are you available to volunteer?


CAFSS:                       Weekly


SOS:                         Fortnightly                 Monthly




WHEN YOU HAVE COMPLETED THIS FORM, PLEASE SEND TO:

DRUG ARM AUSTRALASIA
1/14 COURT ROAD
FAIRFIELD
NSW 2165 PO BOX 1030

OR FAX TO: (02) 9755 0593




                                            DRUG ARM AUSTRALASIA
                  1/14 COURT ROAD FAIRFIELD NSW 2165 PO BOX 1030 Ph: (02) 9755 0596 Fax: (02) 9755 0593
                                               ABN 64 102 943 304
HR-006/2                                                    Issue: 2                                      4/01/2010