CVS Application Form

Community Visitors Scheme Application Form

Thank you for your enquiry regarding the Community Visitors Scheme.

For more information on the role of a Community Visitor please visit http://sacommunityvisitors.com/

If you would still like to explore becoming a CVS volunteer, then please answer the questions that follow. This is our online application form and in order for it to be processed you need to work through all the questions until you reach the last page. I also invite you to meet in order to discuss the CVS program in more detail and give you the chance to ask any questions you may have. This can be done either before or after filling out the application form. During that meeting I will also arrange for a Criminal History Background check which is mandatory for anyone working or volunteering with vulnerable people. Having a previous conviction will not necessarily bar you from becoming a volunteer with the scheme. Again I can discuss that further at our meeting.

Thank you for your interest, I look forward to meeting you soon!

Privacy statement
Southern Volunteering strives to act with the highest integrity and offer the best possible services to volunteers, organisations and other people who access our services. To provide the highest standard of service to all its stakeholders, from time to time Southern Volunteering needs to collect personal information. Such information entrusted to Southern Volunteering is treated with the appropriate degree of privacy. Personal information is any information that an individual’s can be reasonably determined from. Southern Volunteering’s privacy policy and procedures are reviewed in accordance with changes in the law. Volunteer personal information will be held in a secure area for 7 years and then confidentially destroyed.

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* 1. Full Name

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* 2. Preferred name

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* 3. Address

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* 4. Contact telephone number(s)

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* 5. Email address

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* 6. Date of Birth

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* 7. Gender

Male

Female

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* 8. Occupational Group

Full time employed

Part time/casual employed

Unemployed

Unable to Work

Retired

Student

Houseperson

Other (please specify)

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* 9. Birth Country

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* 10. Additional languages spoken

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* 11. Religion

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* 12. How did you hear about the Community Visitors Scheme?

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* 13. Will you be able to visit a resident at least once a fortnight?

Yes

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* 14. Do you have a drivers licence?

Yes

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* 15. Do you have access to a car?

Yes

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* 16. Do you understand you will have to undergo a police check? (please note: an existing criminal conviction will not necessarily bar you from becoming a CVS volunteer)

Yes

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* 17. New regulations require all visitors to Aged Care Facilities to have the seasonal flu vaccination. Are you willing to have this vaccination annually?

Yes

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* 18. Do you have any health limitations for volunteering?

Yes (please provide details below)

If you have answered yes please provide details so we can ensure we support you appropriately

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* 19. Please detail any other special requirements you may have that will enable volunteering with the Community Visitors Scheme to be a positive experience for you

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* 20. Would you like to attend training sessions and volunteer meetings? (please note: attendance at training and volunteer meetings is not compulsory)

Yes

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* 21. Resident match preferred

Male

Female

No preference

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* 22. Availability (please tick all that apply)

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Morning	Morning Monday	Morning Tuesday	Morning Wednesday	Morning Thursday	Morning Friday	Morning Saturday	Morning Sunday
Afternoon	Afternoon Monday	Afternoon Tuesday	Afternoon Wednesday	Afternoon Thursday	Afternoon Friday	Afternoon Saturday	Afternoon Sunday

Or if your availability may vary each week please comment here

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* 23. Aged Care Facility Preferred (please tick all that are suitable)

ViTA @ ACH, 17 Rockville Avenue, Daw Park

Fullarton Residential Care (Southern Cross)

The Lodge, Wayville

Carlysle on Cross, Glen Osmond

Bupa Morphettville, 29 Austral Terrace, Morphettville

Rembrandt Court Dutch Aged Care Home, 1 Madras Street, Oaklands Park

Resthaven Bellevue Heights, 47 Eve Road, Bellevue Heights

Estia Health Daw Park, 7 Lancelot Drive, Daw Park

Estia Health Flagstaff Hill, 44a Skyline Drive, Flagstaff Hill

Southern Cross Lodge, 393 Morphett Road, Oaklands Park

Estia Health Aberfoyle Park, 39 Campus Drive, Aberfoyle Park

Aldinga Beach Court Hostel, Pridham Boulevard, Aldinga Beach

Kalyra Woodcroft Nursing Home, 54 Woodcroft Drive, Morphett Vale

The Vales Aged Care Facility, 60-66 States Road, Morphett Vale

Eldercare Cottage Grove, 150 Reynell Road, Woodcroft

Reynella Lodge, 7 Railway Terrace, Reynella

Perry Park, 26 River Road, Port Noarlunga

Onkaparinga Lodge, Liddell Drive, Huntfield Heights

Holly Aged Care Facility, Penneys Hill Road, Hackham

Christies Beach, 50 Gulfview Road, Christies Beach

Colton Court , 84 Valley View, McLaren Vale

Kalyra Vale Aged Care Village, 19 Aldersey Street, McLaren Vale

Seaford Eldercare, 657 Grand Boulevard, Seaford

All Hallows Nursing Home, Westbourne Park

Glenrose Court Nursing Home, Glen Osmond

Kalyra, Belair

Regis Residential Aged Care, Kingswood

Mitcham Residential Care Facility, Mitcham

Resthaven, Mitcham

Resthaven, Westbourne Park

ACH, Goolwa

ACH, Yankalilla

A Victor Harbor / Encounter Bay Facility

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* 24. Reasons for volunteering. Please briefly state why you wish to become a Community Visitor.

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* 25. Experience. Please describe any experience you may have in supporting older people and/or any experience in hostels or aged care facilities (not essential)

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* 26. Interests. Please list your interests and hobbies (past and present)

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* 27. Life experiences / background. Please identify any particular life experiences (e.g. travel, occupations, where you have lived)

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* 28. Please provide the names and addresses of two referees and their relationship to you. Please note, family members cannot be referees. In addition please ask your nominated referees for permission to provide their name and address before submitting this application form

Name

Email Address

Phone Number

Relationship to you

Name

Email Address

Phone Number

Relationship to you

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* 29. Please provide the name and contact details of an emergency contact

Name

Email Address

Phone Number

Relationship to you

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* 30. Special dietary requirements (for catering at CVS meetings)

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* 31. Please tick to sign the form

Signed

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* 32. Please tick the box below to agree that your contact details can be provided to aged care facilities where you will be visiting a resident as a participant in the Community Visitors Scheme

Permission given