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* 1. Applicant Details

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* 2. Date of Birth (for WWC verification):

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* 3. Gender:

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* 4. Do you speak a language other than English

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* 5. If yes, what other language?

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* 6. What culture do you identify with?

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* 7. Do you have any health conditions or disability that may impact on your involvement in the program?

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* 8. If yes, please explain (or call the Youth Frontiers Coordinator if you prefer this option):

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* 9. Do you identify as: (choose as many as you like)

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* 10. Emergency Contact

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* 11. Referee 1 Details

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* 12. Referee 2 Details 

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* 13. How did you hear about the program? (select all that apply)

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* 14. Tell us why you are interested, and what skills and qualifications you have that will help you to do a great job. Maximum 500 characters.

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* 15. I am prepared to commit and devote to the Youth Frontiers Program, every week for the specified times (including debrief) for a minimum of 6 months commencing in April/May 2019.

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* 16. Career information

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* 17. Name of Employer or Educational Institution if applicable:

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* 18. Can we contact you at work?

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* 19. Would you be available for interviews during business hours?

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* 20. If no, what times (Monday to Friday) would suit you?

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* 21. What education level have you achieved and what did you study?

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* 22. Have you done any previous volunteering? And if so, what did you do?

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* 23. Note: if you choose not to consent to the checks and information requested in Questions 23 to 29, we will not be able to consider your application. Any offer of a voluntary placement will be subject to satisfactory checks. 

Would you be able to obtain a clear National Police Check? (We will organise the Police Check)

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* 24. Do you give Mid Coast Communities permission to lodge your police check electronically on your behalf?

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* 25. Do you currently hold a Working with Children Clearance (WWC)?

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* 26. If so, what is your WWC number?

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* 27. If not, are you able to confirm that you have applied for a WWC and will be able to receive a clearance?

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* 28. If so, what is your application number (APP)?

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* 29. Do you agree to undertake a 100 Point Identity Check?

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* 30. Privacy Notice and Authorisation for Release of Personal Information.
All personal information will be collected and handled by Mid Coast Communities and YWCA Australia in accordance with the Privacy Law and our respective Privacy Policies.

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* 31. Collection

The personal information (including sensitive and health information) that is collected by Mid Coast Communities on behalf of YWCA Australia is information necessary for its functions and activities in relation to the delivery of Youth Frontiers.  In particular, it is necessary to:
  • assess suitability
  • promote health and safety
  • promote the best interests of the child
Mid Coast Communities/YWCA Australia may request disclosure of personal information during the application and selection process and from time to time during participation in the program. If you do not provide this information, we may not be able to process your application or you may be removed from the program.

Where you provide personal information about other people, you must ensure that those people are aware that this information is being collected and used by YWCA Australia for its functions and activities.

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* 32. Disclosure


Generally, your personal information will be kept in the strictest confidence. However, relevant information will be released in limited circumstances where:
  • disclosure is consistent with the primary purposes for which the information was collected;
  • where you have provided your consent to the disclosure of such information; or
  • where the law otherwise requires or authorises us to disclose that information.
For example, your personal information may be disclosed to parents and/or guardians with a direct responsibility for the mentee who has been pre-screened and is actively being considered for a match with you. Your name will be kept confidential until you are matched to a mentee.

We may also provide personal information about individuals to Mid Coast Communities/YWCA Australia service providers/the participating school, or others who assist us in providing services, including (amongst others) legal or professional advisers, mail service providers, insurers, law enforcement agencies, welfare and community agencies, therapists, physicians or hospitals. 

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* 33. Access

You may request access to your personal information by contacting Mid Coast Communities or YWCA Australia.

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* 34. Authorisation 

  • I acknowledge that it is necessary for Mid Coast Communities on behalf of YWCA Australia to collect personal information about me in order to discharge its functions and activities.
  • I undertake to co-operate with the collection of personal information during the selection process and, if I am accepted into the program, as required from time to time.
  • I understand that I am required to inform Mid Coast Communities of any changes to my circumstances during my involvement in the program.
  • I understand that a failure to disclose personal information may result in Mid Coast Communities refusing to accept my application or removing me from the program.
  • I agree that a photocopy of this authorisation is sufficient evidence of my consent to the release of any information about relating to me to YWCA Australia.

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* 35. Optional Consent for Evaluation and Research

From time to time, Mid Coast Communities and YWCA Australia conduct research into their services, in order to improve and report on those services. Sometimes this research can be conducted using de-identified information; however on other occasions it is preferable for personal information to be used. By providing the consent below, you can contribute to improving the effectiveness of this research.

By selecting 'I agree' below, I agree to personal information (including sensitive and health information) held by Mid Coast Communities on behalf of YWCA Australia about me being used and disclosed by Mid Coast Communities or YWCA Australia and its research providers. This information will be subject to confidentiality obligations and I understand that my personal information will not be included in the published findings of that research without my further consent.

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* 36. I agree the information I have included in this document is true and accurate.

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* 37. Name of applicant

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* 38. Signature of applicant: Submitting this form constitutes my electronic signature.

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* 39. Date:

Date / Time
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