Expression of Interest for Volunteer Visitor

Question Title

* ABOUT YOU:

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

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:

	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:

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.

Name:

Address:

Relationship:

Phone:

Name:

Address:

Relationship:

Phone:

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.