St John Ambulance Australia (NSW) Membership Application Form

I apply to become a member of St John Ambulance Australia (NSW) (the Company) and in doing so to be bound by the Constitution. Full Name (Mr, Mrs, Ms, Miss) please print............. Address: .............................. .. Postcode ................................. Phone H: ........ W: ......... M: .......... Email: ......... Date of Birth: ... Working with Children Check verification number: (See WWCC Fact sheet, page 2) What program would you like to volunteer in? (Mark all that are relevant) First Aid Services Volunteer (Please also read and complete pages 4 and 5) First Aid in Schools Program to Aid Literacy (PALs) Immunisation Support Program Ophthalmic Care Other . Note: Please be aware that if you are NOT volunteering in a First Aid Services program you are NOT required to complete or read pages 4 and 5. IN THE EVENT OF AN EMERGENCY, I WOULD LIKE THE FOLLOWING PERSON ADVISED: First Name.............Surname... Relationship (Spouse, parent, guardian etc.) Address ............................... .. Postcode ................................. Phone H: ........ W: ......... M: .......... Fax H: .. W: .. Email ......

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St John Ambulance Australia (NSW) Membership Application Form

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Fact Sheet
St John Ambulance Australia (NSW) houses a diverse range of programs and activities, all of which directly work with Children or have a high propensity to come in contact with children. As part of the Child Protection (Working with Children) Act 2012, we as an organisation are now required to have adult employees and volunteers, who have face-to-face contact with children, complete a Working with Children Check as a part of becoming a member with St John (NSW). For more information please go to www.kids.nsw.gov.au STEP 1: Fill in an application form online (or call Customer Support Officer on (02) 9286 7219 if you do not have internet access) Go to www.newcheck.kids.nsw.gov.au and fill in the online application form. You will be asked whether your child-related work is paid or unpaid. When filling out the application form, under the drop down tab Child-related Sector, please choose the most relevant option that pertains to the St John (NSW) program you are volunteering with: ! ! ! ! ! First Aid in Schools - Childrens Health Services First Aid Services /Training - Clubs or other bodies providing services to children Program to Aid Literacy (PALs) - Clubs or other bodies providing services to children or Parent Volunteer - Mentoring (where applicable) Immunisation Support Program - Childrens Health Services Ophthalmic Care - Clubs or other bodies providing services to children

Please ensure all fields are correct and accurate. In the event of any incorrect spelling of names, you will not be cleared and will NOT be able to amend your application form once submitted. Once you have submitted the application form, you will receive an application number. For example: APP1234567V (the V means it is only valid for unpaid work i.e. volunteering) or APP1234567E (the E means it is for paid work). STEP 2: Present proof of your identity Go to a NSW motor registry or NSW Council Agency that offers Roads and Maritime Services with: ! Your application number AND ! Proof of your identity (100 points of ID as indicated in the CRC form). Note: As a volunteer your check is free. You will not be required to prove that you are a volunteer. Results You will receive your outcome and Working with Children Check number by email (or post if you do not have an email address) direct from the Office of the Childrens Guardian. Most applications will be processed within 48 hours. ! Clearance - Is valid for five years and may be used for any child-related volunteering/work in NSW and is subject to ongoing monitoring for relevant new records. ! Barred - It is an offence to engage in any child-related work (paid or unpaid) and penalties apply. STEP 3: Send in your application for membership Once you have received your WWCC verification number you will need to complete the relevant section, on page 1, of the St John Ambulance Australia (NSW) Membership Application Form, and send the completed form to the St John (NSW) Burwood office, or relevant Division if volunteering in First Aid Services.
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Photography / Name / Story / Incident Release Form

St John Ambulance Australia (NSW) is a self-funded charity that provides and promotes first aid and community services in the community through training and volunteering. St John (NSW) regularly publishes images to promote the work it does. To do this St John (NSW) requires your written permission to use your personal details in association with material being compiled to promote St John (NSW). Please complete the following declaration: I . give permission for St John (NSW) to use my/ my childs photographic image / first and last names / story / incident for promotional and advertising purposes regarding St John (NSW) training, volunteering and commercial activities. This might include printed or electronic publications, websites or other electronic communications. I authorise the use of these images without compensation to me. Name: . My Childs Name: .. Childs Age: .. (if applicable) Signed: Date: Contact phone number: .. (In case we need to contact you in the future) Thank you for allowing St John (NSW) to use your photographic image / first and last names / story / incident which will help to promote the work we do and the importance of first aid and other services in the community. If you have any questions, please call 02 9745 8880

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St John Ambulance Australia (NSW) Membership Application Form

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First Aid Services Application

Adult Division Region
(Please Tick)

North West Sydney Northern Southern South West Sydney Western University Professional Non-Clinical

Membership Type
(Please Tick)

FAS Adult

Cadet / Junior- Unit Region Division Membership Type

(Please Tick)

Region
(Please Tick)

North West Sydney Northern Southern South West Sydney Western University Probationary Cadet Cadet

St John Junior

Parent / Guardian Declaration / Cardio-Pulmonary Resuscitation (CPR) Information and Declaration By signing this form, I give permission for the applicant to join St John Ambulance Australia (NSW). I concur with the agreement they signed and understand that whilst every care will be taken when on St John activities, St John (NSW) and its Officers are not held responsible for any accidents or illness, which may occur. By signing this form, I also agree to indemnify St John (NSW) and its Officers against any claims, by reason of any accident, sickness or otherwise. CPR which is a combination of Mouth-to-Mouth Resuscitation and External Cardiac Compression (sometimes called Heart Massage) is fairly reliable method of sustaining life in clinically deceased people when carried out correctly. Most children of cadet age are physically capable of carrying out CPR on their peers and often adults. Consideration has been given, however, to the possible psychological trauma, which could be experienced by younger cadets; this could result from two possible causes. Firstly, children who attempt CPR may suffer if their patient dies, even if CPR was conducted correctly. Secondly and conversely, children may be upset if they encounter a patient with a cardiac arrest and are unable to help because they have not been taught the fundamentals of CPR. With these two factors in mind, parents/guardians are required to decide whether they wish their child to be taught CPR. They should feel welcome to discuss the matter with the Divisional Management before completing the declaration. I give permission for the applicant to be taught CPR by qualified St John (NSW) trainers from: (a) The date of his/her joining St John (NSW) (b) The date of his/her 14th Birthday (able to complete Senior first Aid Certificate) Name: .. Date: .. Signed: Witnessed by MIC/OIC/Super Name: .. Date: Signed:

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St John Ambulance Australia (NSW) Membership Application Form

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St John Ambulance Australia (OB16)

Understanding of Ability This declaration is to be completed when an application is made to volunteer as a St John First Aider, St John First Responder or St John Advanced Responder in St John Ambulance Australia activities. I understand that, as a member of St John Ambulance Australia, I may be required to perform a variety of tasks and duties and assume responsibilities including those listed below: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. To perform first aid duties in all circumstances including emergency and stressful situations which have been explained to me. To work as part of a team and accept directions. To communicate orally with casualties, fellow workers and the public in various environments and appropriately complete a Casualty Report form (OB12). To be fit enough to perform effective one person adult Cardiopulmonary Resuscitation on the floor for 5 minutes. (This ability will be assessed annually) To carry a first aid kit and other emergency apparatus, weighing up to twenty kilograms, a reasonable distance to a casualty and administer first aid in a timely manner in a variety of environments. To assist in lifting and moving a casualty if needed and carry, with the assistance of one or more people, a casualty on a stretcher a reasonable distance. To undertake study programs, participate in gaining and developing the knowledge and skills relating to first aid and use the knowledge and skills acquired from such study programs. To recognise limits of first aid and my abilities and be ready to ask for help. To take precautions for my safety and those for whom I am caring, including maintenance of personal immunisation status and carrying out of protective measures (e.g. wear protective gloves) consistent with the duties to be performed. If at any time, even at the time of this declaration, it becomes apparent, or there is reason to believe, that I am unable to safely and effectively perform the duties and requirements of my position, I may be invited to attend a medical assessment for a Review of Ability by a St John Ambulance Australia medical officer or I may elect to have this assessment, at my expense, by a private practitioner of my choice.

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St John Ambulance Australia (NSW) Membership Application Form

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Declaration

I have read, signed (where required) and attached the following documents to this application: St John NSW Application for membership form Photo release form (Signature Required) Criminal Record Check Form (Signature Required) Verified copies of 100pt of ID (by a JP or course trainer) First Aid Services Application - If volunteering in First Aid Services (Signature Required) Declaration (Signature Required) Emailed/enclosed a colour photograph (e.g. passport photo) for the preparation of an identity card Emailed/enclosed a copy of relevant qualifications (i.e. First Aid Qualification) If accepted as a member of St John Ambulance Australia (NSW) I acknowledge and agree to read and abide by all current and future policies, procedures and regulations of St John (NSW), as outlined and accessed through the Members website and that I will support the aims and objectives of St John (NSW) on all occasions. I understand that the information I have supplied may be subject to verification and that St John (NSW) has the right to accept or reject my application, without giving reasons. I understand that personal information contained within this form shall only be made available to relevant and my application form will be kept in a secure place in accordance with St John (NSW) privacy policy. I acknowledge that: (a) Any false or misleading statements could lead to disciplinary action (b) There are health risks associated with smoking, excess alcohol intake and the use of illicit drugs. These activities may also adversely affect my ability to effectively serve the community, and St John Ambulance Australia has a duty to ensure that all members are able to function safely and effectively (c) I am able to fulfill the duties and requirements of my position. If at any time I am no longer able to do so, I will advise the appropriate St John (NSW) personnel at the earliest practical moment. (d) If I am applying to be a First Aid Services volunteer, I have read and agree to the terms laid out in the OB16 on page 5 of this document. I hereby give my consent: (a) For information on this form being collected by St John (NSW) for the purpose of assessing my membership application and accept it may be considered in future applications by St John. (b) For the information on this form may be disclosed to relevant St John personnel involved in the membership process. (c) For St John Ambulance Australia (NSW) to conduct a Criminal Record Check and Working With Children Check and I further acknowledge that membership is subject to a satisfactory CRC, WWCC and risk assessment outcome. Signed: Warm regards, Member Support team St John Ambulance Australia (NSW) 9 Deane Street Burwood NSW 2134 T: 02 9745 8704 F: 02 9745 8855 E: hr@stjohnnsw.com.au Date: .

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St John Ambulance Australia (NSW) Membership Application Form

Version 1.0 June 2013