## page was renamed from 5.2.2 Screening Questionnaire for Volunteers #acl NeilSkilton:read,write All:read <> == 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ever had permission to undertake paid or volunteer work with children or other vulnerable people refused, suspended or withdrawn in Australia or any other country?|| || || ||5.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 Has your driver’s licence ever been revoked or suspended?|| || || ||7.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|| ||<
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>|| || || || === CONSENT TO CRIMINAL HISTORY CHECK AND/OR WORKING WITH CHILDREN CHECK === 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. 1. 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. <> ##Applicant’s signature ______________________________________________________ ##Declared this date ________________________ _____________________ ____________________ ## (Day) (Month) (Year) === 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.