Volunteer Application

Volunteer Application

THIS APPLICATION FOR VOLUNTEER DOES NOT GUARANTEE THAT YOU WILL OBTAIN AN INTERVIEW
The information you provide is the first step in our VOLUNTEER process and will enable us to consider you for volunteer work in various areas of the organisation.

We may seek confirmation of details from referees or other sources.
The details provided remain confidential to our organisation or appointed recruitment agency and will not be provided to any other person.
PERSONAL INFORMATION
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Email
example@example.com
Date of Birth

Month Day Year
Date
Country of Birth:
Languages spoken other than English:
Next of Kin / Emergency Contact Details:
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Mobile Number

Area Code Phone Number
Work Number

Area Code Phone Number
INFORMATION ABOUT THIS APPLICATION
What type of volunteer work are you seeking with our organisation?
What type of volunteer opportunity are you seeking? (Tick one or more of the following).

Full Time Part Time Casual Day Work Shift Work Weekend Work More than 20hrs / week Less than 20hrs / week
Do you have any qualifications/certificates relevant to the type of volunteer work you are seeking?
Do you have any prior experience relevant to volunteering?
PREVIOUS VOLUNTEER OR WORK EXPERIENCE HISTORY
Name of most recent volunteer organisation (if applicable):
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Contact Name:
Position Held:
Reason for leaving:
Start Date

Month Day Year
Date
Finish Date

Month Day Year
Date
Please provide details of other previous employers:
Business / Organisation Name:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Contact Name:
Position Held:
Reason for leaving:
Start Date

Month Day Year
Date
Finish Date

Month Day Year
Date
Business / Organisation Name:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Contact Name:
Position Held:
Reason for leaving:
Start Date

Month Day Year
Date
Finish Date

Month Day Year
Date
Please provide details of any previous volunteer experience:
PERSONAL HEALTH INFORMATION
Do you currently or have you ever had or sought medical attention for pain in your back, neck,arms, shoulders, hands, or wrists?

Yes No
If Yes, please list details:
Do you currently or have you ever had or sought medical attention for pain in your hips, legs,knees, feet or ankles?

Yes No
Type a question
If Yes, please list details:

Do you currently or have you ever had or sought medical attention for any of the following?

	Yes	No
Epilepsy, blackouts, fits
Allergies
Hearing problems
Hernia, ulcers
Mental or nervous disorder
Blood disorders
Respiratory problems (e.g. asthma, emphysema)
High or low blood pressure
Heart complaint
Diabetes
Headaches (e.g. migraine)
Sight disorders, eye problems
Fractured or broken bones
Skin problems (e.g. eczema, dermatitis)

Are you aware of any reason which may prevent you from performing the following tasks?

	Yes	No
Wearing vinyl / rubber gloves
Lift heavy objects, make beds
Use vacuum cleaners, mops
Use soaps, detergents, bleaches
Write reports and documents
Use computers, telephones
Wear workplace approved shoes for long periods of time

GENERAL INFORMATION
Why are you applying for volunteer work ?
Have you ever made a claim for Worker’s or M.A.I.B. compensation?

Yes No
If Yes:-
Date of Claim

Month Day Year
Date
Employer Name:
Name of Insurance Company:
Reason for claim:
Please list any personal qualities you have which you believe may assist your application.
Please provide details of two people we may contact as referees if you have not stated them on your resume. They are NOT to be family members and where possible, one to be from your last place of employment.
Employment Referee:
Name:
Occupation:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Work Number

Area Code Phone Number
Mobile Number

Area Code Phone Number
Name:
Occupation:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Work Number

Area Code Phone Number
Mobile Number

Area Code Phone Number
DECLARATION OF APPLICANT
I hereby authorise Meercroft Care Inc to obtain references and speak to referees to verify any
information relevant to this application.
I certify that the information given in this application is true and complete and I am aware that any inaccurate statements made herein or information deliberately withheld may later jeopardise my employment and / or some entitlements claimed by me under worker’s or other forms of compensation.

I acknowledge that this application does not constitute an offer of employment and that any offer subsequent to this application will be subject to satisfactory completion of a preemployment medical examination and satisfactory completion of a probationary period.

Should this application be successful, I agree to abide by all rules, policies and procedures of Meercroft Care Inc.
Applicant Name:

First Name Last Name
Signature of Applicant:

Clear
Witness Name

First Name Last Name
Signature of Witness:

Clear
Date

Month Day Year
Date
Should be Empty:

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