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Volunteer blue card renewal form

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                                                                                                                  V
                                                                                                            RENEWAL

                     Volunteer blue card renewal form
The Commission for Children and Young People and Child Guardian Act 2000 requires anyone over 18 seeking to work
with children under 18 years of age in certain categories of regulated employment to obtain a blue card.
How to fill out this application form
To avoid delays in processing this application please print clearly               Applications for volunteers are
using BLOCK LETTERS and ensure:                                                     processed free of charge.
   t
•	 	 he	organisation/volunteer	co-ordinator	completes	                        Volunteers must hold a valid blue card
   Parts A, C and D                                                            before they commence child-related
•	 the	volunteer	completes	Part B                                               employment regulated by the Act.
•	 you	indicate	with	a	tick	where	required.
Note: It is an offence for a volunteer to provide false or misleading information to the Commission or to sign an application
for	a	blue	card	if	they	are	a	disqualified	person# (see page 4).

PART A Organisation’s Details (this section	must	be	completed	by	the	organisation/volunteer	co-ordinator)
 1	 Name	of	organisation		                                       6 Type	of	child-related	employment	for	which	a	
                                                                   blue card is sought (please tick appropriate box)
     Surf Life Saving Queensland
                                                                 	 	 residential facilities

                                                                 	 	 schools (other than registered teachers)*
                                                                     	
     Organisation ID number                                          school boarding houses
     (please insert the Commission’s reference number
                                                                 	 	 	
     for your organisation if known)                             	 	 child care›

                                                                 	 x	churches, clubs and associations®

                                                                 	 	 health, counselling and support services
 2 Postal address of organisation
                                                                 	 	 private teaching, coaching or tutoring
      PO Box 3747
                                                                 	 	 education programs outside of school
      South Brisbane QLD
                                                                     child
                                                                 	 	 accommodation including homestays
                                                                 	 	 religious representatives
                                      Postcode: 4101                 sport and active recreationº
                                                                 	 	
                                                                 	 	 emergency services cadet program
 3 Contact person
                                                                 	 	 school crossing supervisors
      John Brennan
                                                                        	volunteer of the licensed care service

 4 Contact person’s position                                            	volunteer working for a business providing
                                                                         	
                                                                         services at a licensed care service
     Executive Manager
                                                                 Note:	Exemptions	apply	in	certain	circumstances,	
                                                                 eg. a parent is exempt if they provide services:
 5 Phone           07 3846 8000                                  * at the school their child attends
     Email         jbrennan@lifesaving.com.au
                                                                 ›
                                                                   at a centre where their child regularly receives child care
                                                                 ®	within a church, club or association which are the same
     Fax           07 3846 8008                                    or similar to those received by their child
                                                                 º as part of sport or active recreation involving their child
 Additional Information                                          The organisation is responsible for declaring that the
 The word “organisation” is taken to mean “employer”             volunteer is not exempt (see Part D).
 for the purposes of complying with the Act.

Applicant’s	Name                                                                                          CCYPCG	04-130	JUNE09	v1.1
                                                                                                                                      1
     PART B Volunteer’s Details                                           16 If you have lived at a different address in the last
                 (this section must be completed by                          5 years, please detail on a separate sheet of paper
                 the volunteer)                                              and tick this box
                                                                          17 Your telephone numbers
     7 Have you ever applied for or held a blue card?
          Yes          No                                                    Daytime
     	 Blue	card	No.	(if	known)	                                             After hours
     8 Your title           Mr       Mrs          Miss               Ms      Mobile
                          Other                                           18 Do you identify as? (please tick)

     9 Name	you	presently	use                                                    Aboriginal            Torres Strait Islander

     	   Family	Name	                                                            Aboriginal and Torres Strait Islander

     	   First	Name	                                                             Australian South Sea Islander

     	   Middle	Name	                                                            Other (specify)

         I do not have a middle name (please tick)                        19 What language do you mainly speak at home?

     10	 	 o	you	currently	use	an	abbreviation/nickname/alias	
         D                                                                       English           Other (specify)
         for	your	first	name?	eg. Elizabeth abbreviation Betty
         Name/s	                                                          20 Are you, or have you ever been, any of the following
                                                                             in	Queensland	(please	tick	the	appropriate	box/es):
     11	 	 ave	you	ever	been	known	by	any	other	name/s?	
         H
                                                                                  registered teacher
         This includes:
     	 •	 name	at	birth	              •	 married	name                             carer approved by Dept of Communities
     	 •	 change	following	divorce	 •	 alias                                      (Child Safety Services)
            m
     	 •	 	 aiden	name		              •	 change	by	certificate/                   registered health practitioner
            (name before marriage)       deed poll
     	 •	 	 hange	the	order	of	your		 •	 	 ifferent	first/middle	
            c                            d                                        registered or enrolled nurse or midwife
            name (eg. known by           name (eg. different                      licensee of a child care service
            middle name)                 abbreviations)
         Note: It does not matter how long ago you changed                        director or nominee of a care service licensed by
         your name or how long you used another name for.                         the Dept of Communities (Child Safety Services)

     	   (Please	tick)	    No        Go to question 12                            director of a school’s governing body

                           Yes       give details below:                  21 Volunteer’s declaration
                                                                             Note:	It	is	an	offence	for	a	disqualified	person	to	
         If you require more space, please tick this box
                                                                             sign a blue card application.# (see page 4)
         and attach a separate list
                                                                             I declare:
     	   Family	Name	                                                           t
                                                                          	 •	 	 he	information	and	identification	documents	
     	   First	Name	                                                            provided for this application are true and correct;
                                                                                t
                                                                          	 •	 	 hat	I	am	proposing	to	undertake	regulated	
     	   Middle	Name	
                                                                                employment and am not entitled to an exemption;
         Reason for change                                                      I
                                                                          	 •	 	 	am	aware	of	my	obligations	as	a	blue	card	
     12 Are you                                                                 applicant/card	holder;
            Male            Female                                        	 •	 	 hat	I	am	not	a	disqualified	person# (see page 4);
                                                                                t
                                                                                I
                                                                          	 •	 	 consent to the Commission obtaining information
     13 Date of birth                             /							/                     from police, courts, prosecuting authorities and other
                                            DAY   MONTH       YEAR              bodies	under	Part	6	and	to	publishing/providing	
     14 Place of birth                                                          confirmation	on	whether	or	not	my	blue	card	is	valid.
         Town/city	                                                          Sign inside the box as your signature will be scanned.
         State
         Country
     15 Current postal address
        (Note: your postal address must be in Australia)


                                                                             Date of signature              /							/
                                                                                                      DAY   MONTH       YEAR
                                           Postcode
    Applicant’s	Name                                                                                                     CCYPCG	04-130	JUNE09	v1.1
2
 PART C Proof of Identity Declaration                             Please indicate which identification documents have
           (this section must be completed by                     been sighted by placing a þ in the box.
           the	organisation/volunteer	co-ordinator)               22 LIST 1
                                                                     Signature Document
The	organisation/volunteer	co-ordinator	is	responsible	for	           Current	driver	licence/learner’s	permit/
sighting the volunteer’s	identification	documents.	               	 			
                                                                          proof of age card (with photo)
                                                                         	
However, in limited circumstances (where the volunteer                    Document No:
resides more than 50km from the organisation’s business                   Issued in the state of:
address or has a disability that affects his or her mobility),
this responsibility can be exercised by a prescribed person.      	      	Current passport (with photo)
                                                                          	
                                                                         Passport No:
                                                                         	
A	prescribed	person	is	a	Justice	of	the	Peace,	
Commissioner	for	Declarations,	Lawyer	or	Police	Officer.		        	 Non-Signature Document
                                                                       	
Irrespective of whether or not the organisation/volunteer             	 Birth certificate	(or	extract)
co-ordinator can sight the identification documents, they                 Reference No:
must complete Part D.                                                    	
                                                                         	Australian	citizenship	certificate	or	current	
                                                                          	
Where the organisation/volunteer	co-ordinator	is	unable                   document evidencing permanent Australian
to	sight	the	identification	documents,	a	prescribed	person	               residency status
must sight them and complete Parts C and E.                               Reference No:

                                                                  23 LIST 2
Identification requirements
                                                                     Signature Document
The volunteer	must	produce	two	original	identification	
                                                                  	 	     Current Pension	Concession	Card/Dept	of	
                                                                          	
documents	to	confirm	their	identity.	Together	the	                        Veterans’	Affairs	Entitlement	Card/Senior’s	
documents must show:                                                    	 Health	Card	/Health	Care	Card/any	other	current	
•	 full name                                                              financial	entitlement	card issued by Centrelink.

•	 date of birth                                                  	      	Current Credit Card or account card from a
                                                                          	
                                                                          bank/building	society/credit	union	
•	 signature                                                             	 name and signature)
                                                                         (with

The organisation/volunteer	co-ordinator	must	certify	in	                 	Current	Positive	Notice	Blue	Card	
Part D that the details provided on the application form are              (issued by the Commission)
                                                                         	
the same as those appearing on the documents sighted.             	      	Current student	identification	card	issued	by	
                                                                          	
                                                                          a tertiary education institution or school
One of the following combinations must be used:                          	 photo and signature)
                                                                         (with
EITHER                                                                    Current Qld Gaming Machine Licence
                                                                  	      		
         List 1 + List 2                                          	      	Current Qld Licence issued under the Weapons Act
                                                                          	
                                                                      Non-Signature Document
                                                                         	
One original document from List 1 and one original
                                                                  	      	Current Medicare card
                                                                          	
document from List 2 which together show the volunteer’s
full name, date of birth and signature.                           	      	
                                                                         	Current	Qld	crowd	controller/private	
                                                                          	
                                                                          investigator/security	officer	licence
OR                                                                       	
                                                                  	      	Passbook or account statement issued by a
                                                                          	
         List 1 + List 1                                                  bank/building	society/credit	union	dated	in	the	
                                                                         	 6 months
                                                                         last
Two original documents from List 1 which together show                    Australian taxation assessment notice dated in
the volunteer’s full name, date of birth and signature.           	      		
                                                                          the last 6 months
Note:	All	identification	documents	sighted	must	be	
                                                                         	
originals (photocopies are not acceptable).                      The	organisation/volunteer	co-ordinator	must	complete	
Where any document is in a former name, an original              Part D.
official	document	(eg.	marriage	certificate	or	change	           Where	the	organisation/volunteer	co-ordinator	is	unable
of	name	certificate)	showing	the	change	of	name	must	            to	sight	the	identification	documents,	a	prescribed	person	
be sighted.                                                      must sight them and complete Parts C and E.
Note:	If	you	cannot	provide	an	identification	document	
from either List 1 or List 2 please contact the Commission
on 07 3211 6999 or 1800 113 611.
If possible, please attach a photocopy of documents
sighted	to	this	application	form	for	verification	purposes.



Applicant’s	Name                                                                                           CCYPCG	04-130	JUNE09	v1.1
                                                                                                                                       3
     PART D Declaration by Organisation/                                Privacy notice
            Volunteer Co-ordinator                                      The Commission for Children and Young People and
                 (to	be	completed	by	the	organisation/                  Child Guardian Act 2000 allows us to collect your
                 volunteer	co-ordinator)                                personal information, which is accessed by Commission
                                                                        staff to assess your application for a blue card.
     It is an offence to provide false or misleading                    Some of this information goes to Queensland Police,
     information to the Commission.                                     and may be sent to interstate or federal police to
     I declare that:                                                    conduct criminal history checks. Information may also
     •		 	am	authorised	to	submit	this	application	on	behalf	of	
        I                                                               be given to:
        the organisation; and                                           •	 certain	disciplinary	bodies	to	get	relevant	disciplinary	
     •		 he	volunteer	is	proposing	to	undertake	regulated	
        t                                                                   information about you
        employment and an exemption does not apply; and                 •	 your	employer,	any	supervisory	body,	or	other	person	
     •		 	have	warned	the	volunteer	that	it	is	an	offence	for	a	
        I                                                                   you have authorised to discuss your application on
        disqualified person to sign a blue card application.                your behalf. This enables us to update them on your
                                                                            blue card application and any changes to your blue
     Please tick appropriate box R                                          card status.
            I have checked the details provided in this                 Advice about your blue card’s validity may also be
            form and confirm they match those on the                    provided through the Commission’s online blue card
            identification documents sighted.                           verification	process.
     OR                                                                 Personal information will not be given to any other
            I am unable to sight the identification documents           person or agency unless we have your permission or the
                                                                        disclosure is authorised or required by law.
            because:
            •		the volunteer’s usual residence is more than             Important information
               50km from the business address, or                       You can withdraw your consent to screening at any time
                                                                        before a decision is made.
            •		the volunteer has a disability affecting his or her
                                                                        #Disqualified people
              mobility.                                                 It is an offence for a disqualified person to sign a blue
     Note: It is an offence not to warn the volunteer that it is        card application form.
     an	offence	for	a	disqualified	person	to	sign	a	blue	card	          A	disqualified	person	is	someone	who:
     application.                                                       •	 has	been	convicted	of	a	disqualifying	offence,
                                                                             ie. a guilty finding or guilty plea, whether or not
     Full	Name                                                               a conviction was recorded. This may include a
                                                                             child-related	sex	or	pornography	offence	or	the	
     Signature                                                               murder of a child (irrespective of the penalty and
                                                                             regardless of when and where it occurred);
     Position                                                           OR
     Date                   /							/                                   •	 is	the	subject	of:	
                     DAY    MONTH       YEAR                                 | reporting obligations under the Child Protection
                                                                                 (Offender Reporting) Act 2004
                                                                             | an offender prohibition order under the Child
     PART E Declaration by Prescribed Person
                                                                                 Protection (Offender Prohibition Order)
                 (to be completed by a prescribed person)
                                                                                 Act 2008, or
     I declare I have checked the details provided in this                       a
                                                                             | 	 	disqualification	order	issued	by	a	court	
     form	and	confirm	they	match	those	on	the	identification	                    prohibiting them from applying for or holding a
     documents sighted.                                                          blue card.
     Note: It is an offence to provide false or misleading              A	disqualified	person	can	apply	to	the	Commission	to	
     information to the Commission.                                     be declared eligible to apply for a blue card in certain
                                                                        limited circumstances.
     I am a:                               Stamp	or	Registration	No.	
                                               (if applicable)
                                                                        For more about blue card information and obligations
     	      	
            Justice	of	the	Peace                                        go to www.bluecard.qld.gov.au
     	      	
            Commissioner for
              Declarations
     	      	
            Lawyer                                                                 Please mail this completed form to:
     	      	
            Police	Officer                                                             Surf Life Saving Queensland
                                                                                                PO	Box	3747
     Signature                                                                          South Brisbane Qld 4101
                                                                                           Phone: 3846 8000
     Full	Name
                                                                                            Fax: 3846 8008
     Date                   /							/
                      DAY    MONTH      YEAR

    Applicant’s	Name                                                                                            CCYPCG	04-130	JUNE09	v1.1
4

				
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Description: Volunteer blue card renewal form