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GIRL GUIDES TASMANIA ADULT MEMBER REGISTRATION FORM

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					TADM.15


                                                      GIRL GUIDES TASMANIA
                              ADULT MEMBER REGISTRATION FORM
PERSONAL DETAILS
Title: (Mrs/Miss/Ms/Dr)                              Given Name:                                                      Family Name:

Address: ......................................................................................................................................................................
............................................................................................................................................   Postcode: .....................
Home phone:                                                      Work phone:                                                        Mobile:
Occupation:                                                      Email:                                                             Date of Birth:
Country of Birth:                                                Language Spoken at Home:

MEMBERSHIP TYPE: (please tick the appropriate box)
□        Leader                                    □            Youth                     □             Adult                     □            Resource
□        General
□        State Appointment
□        Unit Helper
□        Guiding Assistant
□        Other, please explain

This section to be completed by Leaders, Unit Helpers and Guiding Assistants:
UNIT
DISTRICT
DIVISION

PREVIOUS GUIDING EXPERIENCE (include any appointments held or service to Support Groups or District
Management Teams- full details of dates, state, location etc. If insufficient space, please include an attachment):




EXPERIENCE WORKING WITH PEOPLE (ADULT AND/OR YOUTH):




INTERESTS/SKILLS: (optional)




MEDICAL INFORMATION
 Medicare Number: (include Reference Number)                                                                        Expiry Date:

 Private Health Fund Name:                                                                                            Number:




TADM.15 Adult Member Registration Form                                             page 1 of 4                                                                          Version 1
                                                                                                                                                 Current Issue: 25 February 2008
                                                                                                                                                 Original Issue: 25 February 2008
                                                                                                                                                  Review Date: 25 February 2009
TADM.15
  Name of Preferred Doctor or Medical Centre:
  Telephone Number:

  Details of allergies, disabilities, health conditions, long term medication:




1.    I authorise the relevant State or Territory Girl Guide organisation to obtain first aid, medical, ambulance, dental assistance or
      treatment, including any anaesthetic or blood transfusion, for myself in the event of any illness or accident. (Note: All
      reasonable attempts to make contact with the nominated “person to contact in an emergency” will be made.)
2.    I agree to pay for all expenses incurred in obtaining such medical aid and to reimburse the organisation for any expenses
      incurred. NB: Organisation – includes its officers, agents, employees or representatives


EMERGENCY CONTACTS:                                                    (please give details for two people to contact in an emergency)

 Name:                                                                                       Name:
 Address:                                                                                    Address:


 Realtionship to Applicant                                                                   Relationship to Applicant
 Home Phone:                                                                                 Home Phone:
 Mobile:                                                                                     Mobile:

REFEREES – You are required to supply the names and addresses of two referees who have known you for at least two
years and are not related to you.

Title: (Mrs/Miss/Ms/Mr/Dr)                               Given Name:                                                            Surname:

Address: .........................................................................................................................................................................................

.........................................................................................................................................................   Postcode:     ........................
Telephone: Home:                                                  Business:                                             Mobile:

Occupation:

Title:              Given Name:         Surname:
(Mrs/Miss/Ms/Mr/Dr)
Address:………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………..Postcode ………………………………..
Telephone: Home:     Business:     Mobile:

Occupation:

      How did you hear about Guides?
                     Friend                                                                               Relative

                     Media                                                                                Other – please explain




TADM.15 Adult Member Registration Form                                                    page 2 of 4                                                                               Version 1
                                                                                                                                                             Current Issue: 25 February 2008
                                                                                                                                                             Original Issue: 25 February 2008
                                                                                                                                                              Review Date: 25 February 2009
TADM.15
STATEMENT BY APPLICANT
1. I agree to pay any registration fees and any annual membership subscriptions as requested.
2. I acknowledge I have been informed that a copy of Guide Lines (a publication containing the policy,
   organisation and rules of Girl Guides Australia which is updated from time to time) is available for inspection at
   each Girl Guide venue and the sections relating to program, camping, adventurous activities and policies can
   be viewed on the Girl Guides Australia web site (www.guidesaus.org.au); that I have been invited to read this
   publication and that its contents are binding on me.
3. I agree that all copyright for all work and intellectual property produced by me in relation to my participation in
   the Girl Guide program shall be assigned and belong to Girl Guides Australia.
4. I authorise Girl Guides Australia and any person authorised by Girl Guides Australia to reproduce, publish,
   broadcast or do any of the acts comprised in the copyright subsisting in: photographs, video tapes, voice
   recording of me in any form deemed appropriate by Girl Guides Australia. I hereby release Girl Guides
   Australia and the Girl Guide organisations of each State and Territory of Australia, from all claims, demands,
   actions, proceedings, costs or expenses relating to or arising out of use of material. (This clause may be
   deleted by ruling a line through the clause and initialling if desired).
5. I consent to the collection and use of information supplied by me for the operation of Girl Guides Australia and
   the Girl Guide organisations of each State and Territory of Australia. I acknowledge that the information will be
   dealt with in accordance with the Girl Guides Australia Privacy Statement and Policy contained in Guide Lines.
6. I consent to receive promotional material from Gril Guide, please circle,    YES     NO
7. I understand that Girl Guides Tasmania does not have any medical insurance.
8. I agree to provide a recent head and shoulder photo for inclusion on my Girl Guides Tasmania registration card
   and to be kept on record at Girl Guides Tasmania’s State Office to be provided to Emergency Services in case
   of an emergency.


                                            CODE OF CONDUCT
                   Girl Guides Australia requires that each adult member at all times will:

           •    abide by the Guide Promise and Law, the Aims and Principles of Guiding and all other rules
                and policies of Girl Guides Australia and the relevant State organisation;

           •    treat youth members with respect and accept responsibility for the physical and emotional
                safety of youth members, as required by duty of care;

           •    recognise the importance of and encourage the spiritual development of youth members
                according to Girl Guides Australia policy;

           •    not use Guiding to promote personal beliefs, behaviours or practices where these are not
                compatible with Guiding;

           •    adhere to the drugs, smoking and alcohol policies of the organisation;

           •    behave in such a way as to bring credit to Guiding and maintain the standards of Guiding;

           •    respect everyone’s right to privacy;

           •    accept the need to avoid unaccompanied or unobserved activities, including discussion and
                interviews, with individual youth members; and

           •    recognise that physical, sexual or verbal abuse, bullying, tormenting or ridicule is unacceptable
                behaviour by any member and will take appropriate action to deal with such behaviour.




TADM.15 Adult Member Registration Form                 page 3 of 4                                                     Version 1
                                                                                                Current Issue: 25 February 2008
                                                                                                Original Issue: 25 February 2008
                                                                                                 Review Date: 25 February 2009
TADM.15
I authorise Girl Guides Tasmania to make any enquiries it sees fit, as to my character, background and suitability as
a Leader or member. I accept the Girl Guides Australia Code of Conduct and agree to complete the training and
requirements necessary to maintain this appointment.

Signed: ..........................................................................................................................................................................

Date: .............................................................................................................................................................................

Witnessed:......................................................................................................................................................................

Date: ...............................................................................................................................................................................

Division /District Leader /Other (Please specify): Name……………………………………………………………………

Division /District Leader/Other (please specify): Signature……………………………..Date…………………………….




I have completed the application for a Tasmania and National Police Check and have attached the form and
associatied documents to this registration form.

Signature:…………………………………………………………………………….……..Date…………………..………….




      Adult registration form

Please complete this form in duplicate and forward one copy to:

Guide House
25 Kirksway Place
BATTERY POINT TAS 7004 .

The District Leader/Division Leader or appropriate person should retain the other copy.

      Consent to check and release Tasmania and National Police Record

This form is to be completed and returned to Guide House for processing by Tasmania Police. The cost for this
national police check will be paid by Girl Guides Tasmania. A copy of your Criminal List Record will be forwarded to
Girl Guides Tasmania and retained for Association Records.




    This completed form will be retained by Girl Guides Tasmania as a permanent record.


                                                                             OFFICE USE ONLY:
                                                                             Police check received -                          Date_____/_____/_____




TADM.15 Adult Member Registration Form                                            page 4 of 4                                                                          Version 1
                                                                                                                                                Current Issue: 25 February 2008
                                                                                                                                                Original Issue: 25 February 2008
                                                                                                                                                 Review Date: 25 February 2009

				
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Description: GIRL GUIDES TASMANIA ADULT MEMBER REGISTRATION FORM