Screening Questionnaire for Volunteers

Personal Details


Surname:

Given names:

Previous Names:

Male/Female:


Address:

Home phone:

Work phone:

Mobile phone:

Email:

Date of birth:

Marital status:

CONSENT: I consent to the information contained in this application including the subsequent pages to be kept by Avenel-Nagambie and Seymour Uniting Church. I understand that this information will be kept in a confidential file and used only for screening and disciplinary purposes.

Please tick either “yes” or “no” for each question. If the answer is “yes”, please give details on a separate page. NOTE: A “yes” answer will not automatically rule an applicant out of selection.

Question

Yes

No

1. Do you have any health problem(s), which may affect you volunteering for the church?

2. Have you ever be convicted of a criminal offence?

3. Have you ever been charged with a criminal offence?

4. Have you ever had permission to undertake paid or volunteer work with children or other vulnerable people refused, suspended or withdrawn in Australia or any other country?

5. Have you ever engaged in any of the following conduct, even though never having being charged?
• Sexual contact with someone under your care other than your spouse (such as parishioner, client, patient, student, employee or subordinate)
• Sexual contact with a person under the age of consent
• Illegal use, production, sale or distribution of pornographic materials
• Conduct likely to cause harm to people, or to put them at risk of harm.

6. Has your driver’s licence ever been revoked or suspended?

7. Have you ever had an apprehended violence order, order for protection or the like issued against you as a result of allegations of violence, abuse, likely harm, harassment, stalking etc?

8. Has a child or dependent young person in your care (as a parent or in any other capacity) ever been removed from your care, or been the subject of a risk assessment by the authorities?

9. Have you done anything in the past or present that may result in allegations being made against you of child abuse?
Abuse means: bullying; emotional abuse; harassment; neglect; physical abuse; or sexual abuse.

10. Have you done anything in the past or present that may result in allegations being made against you of bullying or any form of harassment of adults?

11. To your knowledge, have you ever been the subject of an allegation of sexual abuse or sexual misconduct?

12. Have you a history of alcohol abuse or a history of substance abuse including prescription, over-the-counter, recreational or illegal drugs?

Record of Christian Church membership

List church organisations, churches, congregations of which you been associated with:-

Name of church

Location

When (month/year)

Positions held





I hereby consent to provide an Australian Federal Police if I have resided in another country. I also consent to provide a National Criminal History Background Check and/or a Working With Children Check.

I,

of

do solemnly and sincerely declare that:

  1. The information I have provided in this application and the information contained in any documents accompanying this application are true and correct to the best of my knowledge and belief.
  2. I understand that any material misstatement in or omission from this questionnaire may render me unfit to hold a particular or any office in the Church.

CHARACTER REFERENCES:

Please provide two (2) referees.

Referees must be over 18 years if age and be able to give a report (by telephone only) on your good character and suitability for ministry.

Referee 1:

Phone:

State your relationship with this person

Referee 2:

Phone:

State your relationship with this person

Witness to the Applicant’s Check

Name of Witness:

Title/Office held:

Signature:

Date:

Note: Please seek legal advice if you are uncertain about signing this document.

SafetyScreeningQuestionnaireVolunteers (last edited 2017-11-19 05:39:20 by JohnHurst)