Expression of Interest for Volunteer Visitor

Question Title

ABOUT YOU: (Required.)

Full Name:

Preferred name:

Gender:

Address:

Suburb & Postcode:

Date of birth (dd/mm/yyyy):

Phone:

Email:

Country of Origin:

Have you lived outside of Australia for more than 12 months after the age of 16? Yes/No:

Are you an Australia citizen? If no, which visa type:

Question Title

Information to help us match you with a senior (Required.)

Do you speak languages (including dialects) other than English? If so, please list:

What have been/are your major areas of education/training?

Indicate previous / current work:

Indicate any previous volunteering experience:

Indicate any previous experience in aged care, including as a family carer:

Do you have other personal or hobbies to share with an older person?

Question Title

Is there any information, medical or otherwise, that you feel we need to be aware of that may affect your volunteering?

Yes

If Yes (please specify)

AVAILABILITY

Question Title

Do you have sufficient time to visit a minimum of once a fortnight (10 visits minimum over a 6- month period). Please indicate your availability: (Required.)

	AM	PM
MONDAY	MONDAY AM	MONDAY PM
TUESDAY	TUESDAY AM	TUESDAY PM
WEDNESDAY	WEDNESDAY AM	WEDNESDAY PM
THURSDAY	THURSDAY AM	THURSDAY PM
FRIDAY	FRIDAY AM	FRIDAY PM
SATURDAY	SATURDAY AM	SATURDAY PM
SUNDAY	SUNDAY AM	SUNDAY PM

Specific Times (if any)

EMERGENCY CONTACT INFORMATION

Question Title

EMERGENCY CONTACTS: (Required.)

Name:

Relationship:

Phone No:

Name:

Relationship:

Phone No:

REFEREES

Question Title

Please provide details of two referees who you have contacted and who have agreed to be your referee when we call. (Required.)

Name:

Address:

Relationship:

Phone:

Name:

Address:

Relationship:

Phone:

Additional

Question Title

How did you hear about us? (Required.)

AfCAS Facebook

AfCAS LinkenIn

AfCAS Website

Other (please specify)

Privacy Information Consent:

I consent to AFCAS collecting personal information about me.

I understand that the collection of this information is required for use in the aged care volunteer visitors scheme.

100% of survey complete.

Expression of Interest for Volunteer Visitor

Question Title

* ABOUT YOU: (Required.)

Question Title

* Information to help us match you with a senior (Required.)

Question Title

* Is there any information, medical or otherwise, that you feel we need to be aware of that may affect your volunteering?

Question Title

* Do you have sufficient time to visit a minimum of once a fortnight (10 visits minimum over a 6- month period). Please indicate your availability: (Required.)

Question Title

* EMERGENCY CONTACTS: (Required.)

Question Title

* Please provide details of two referees who you have contacted and who have agreed to be your referee when we call. (Required.)

Question Title

* How did you hear about us? (Required.)

ABOUT YOU: (Required.)

Information to help us match you with a senior (Required.)

Is there any information, medical or otherwise, that you feel we need to be aware of that may affect your volunteering?

Do you have sufficient time to visit a minimum of once a fortnight (10 visits minimum over a 6- month period). Please indicate your availability: (Required.)

EMERGENCY CONTACTS: (Required.)

Please provide details of two referees who you have contacted and who have agreed to be your referee when we call. (Required.)

How did you hear about us? (Required.)