Volunteer blue card renewal form - Shailer Park Scout Group

VRENEWALVolunteer blue card renewal formThe Commission for Children and Young People and Child Guardian Act 2000 requires anyone over 18 seeking to workwith children under 18 years of age in certain categories of regulated employment to be obtain a blue card.How to fill out this application formTo avoid delays in processing this application please write clearlyusing BLOCK LETTERS and ensure:• the organisation/volunteer co-ordinator completesParts A, C and D• the volunteer completes Part B• you indicate with a tick where required.Applications for volunteers areprocessed free of charge.Volunteers must hold a valid blue cardbefore they commence child-relatedemployment regulated by the Act.Note: It is an offence to provide false or misleading information to an organisation or the Commission.PART A Organisation’s Details (this section must be completed by the organisation/volunteer co-ordinator)1 Name of organisation6 Type of child-related employment for which ablue card is sought (please tick appropriate box)residential facilitiesschools (other than registered teachers)*2 Postal address of organisationschool boarding houseschild care churches, clubs and associationschild counselling and support servicesPostcode:private teaching, coaching or tutoringeducation programs outside of school3 Contact personchild accommodation including homestaysreligious representativessport and active recreation4 Contact person’s positionemergency services cadet programschool crossing supervisors5 PhoneEmailFaxAdditional InformationThe word “organisation” is taken to mean “employer”for the purposes of complying with the Act.volunteer of the licensed care servicevolunteer working for a business providingservices at a licensed care serviceNote: Exemptions apply in certain circumstances,eg. a parent is exempt if they provide services:* at the school their child attendsat a centre where their child regularly receives child care within a church, club or association which are the sameor similar to those received by their child as part of sport or active recreation involving their childThe organisation is responsible for declaring that thevolunteer is not exempt (see Part D).Applicant’s NameCCYPCG 04-130 NOV062

2PART B Volunteer’s Details(this section must be completed bythe volunteer)7 Have you ever applied for or held a blue card?Yes NoBlue card No. (if known)8 Your title Mr Mrs Miss MsApplicant’s NameOther9 Name you presently useFamily NameFirst NameMiddle NameI do not have a middle name (please tick)10 Do you currently use an abbreviation/nickname/aliasfor your first name? eg. Elizabeth abbreviation BettyName/s11 Have you ever been known by any other name/s?This includes:• name at birth• married name• change following divorce • alias• maiden name• change by certificate/(name before marriage) deed poll• change the order of your • different first/middlename (eg. known by name (eg. differentmiddle name)abbreviations)Note: It does not matter how long ago you changedyour name or how long you used another name for.(Please tick) No Go to question 12Yes give details below:If you require more space, please tick this boxand attach a separate listFamily NameFirst NameMiddle NameReason for change12 Are youMale Female13 Date of birth14 Place of birthTown/cityStateCountry/ /DAY MONTH YEAR15 Current postal address(Note: your postal address must be in Australia)Postcode16 If you have lived at a different address in the last 5years, please provide details on a separate sheet ofpaper and tick this box17 Your telephone numbersDaytimeAfter hoursMobile18 Do you identify as? (please tick)AboriginalTorres Strait IslanderAboriginal and Torres Strait IslanderAustralian South Sea IslanderOther (specify)19 What language do you mainly speak at home?EnglishOther (specify)20 Are you, or have you ever been, any of the followingin Queensland (please tick the appropriate box/es):registered teachercarer approved by Dept of Child Safetyregistered health practitionerregistered or enrolled nurse or midwifelicensee of a child care servicedirector or nominee of a care service licensed bythe Department of Child Safetydirector of a school’s governing body21 Volunteer’s declarationI declare:• the information and identification documentsprovided for this application are true and correctand that it is an offence to provide false ormisleading information;• that I am proposing to undertake regulatedemployment and am not entitled to an exemption;• I am aware of my obligations as a blue cardapplicant/card holder;• I give my consent for the Commission to obtaininformation from police, courts, prosecutingauthorities and other bodies for the purpose ofemployment screening under Part 6.Do not sign outside the box as your signature willbe scanned onto your card.Date of signature/ /DAY MONTH YEARCCYPCG 04-130 NOV06

PART C Proof of Identity Declaration(this section must be completed bythe organisation/volunteer co-ordinator)The organisation/volunteer co-ordinator is responsible forsighting the volunteer’s identification documents.However, in limited circumstances (where the volunteerresides more than 50kms from the organisation’s businessaddress or has a disability that affects his or her mobility),this responsibility can be exercised by a prescribed person.A prescribed person is a Justice of the Peace,Commissioner for Declarations, Lawyer or Police Officer.Irrespective of whether or not the organisation/volunteerco-ordinator can sight the identification documents, theymust complete Part D.Where the organisation/volunteer co-ordinator is unableto sight the identification documents, a prescribed personmust sight them and complete Parts C and E.Identification requirementsThe volunteer must produce two original identificationdocuments to confirm their identity. Together thedocuments must show:• full name• date of birth• signatureThe organisation/volunteer co-ordinator must certify inPart D that the details provided on the application form arethe same as those appearing on the documents sighted.One of the following combinations must be used:EITHERList 1 + List 2One original document from List 1 and one originaldocument from List 2 which together show the volunteer’sfull name, date of birth and signature.ORList 1 + List 1Two original documents from List 1 which together showthe volunteer’s full name, date of birth and signature.Note: All identification documents sighted must beoriginals (photocopies are not acceptable).Where any document is in a former name, an originalofficial document (eg. marriage certificate or changeof name certificate) showing the change of name mustbe sighted.Please photocopy the documents sighted and anychange of name documents and attach them tothis application form.Note: If you cannot provide an identification document fromeither List 1 or List 2 please contact the Commission on3247 5145 or 1800 113 611.Please tick the relevant box and record number(where applicable)22 LIST 1Signature DocumentCurrent driver licence/learner’s permit/proof of age card (with photo)Document No:Current passport (with photo)Passport No:Non-Signature DocumentBirth certificate (or extract)Reference No:Australian citizenship certificate or currentdocument evidencing permanent Australianresidency statusReference No:23 LIST 2Signature DocumentCurrent Pension Concession Card/Dept ofVeterans’ Affairs Entitlement Card/Senior’sHealth Card /Health Care Card/any other currentfinancial entitlement card issued by Centrelink.Current Credit Card or account card from abank/building society/credit union(with name and signature)Current Positive Notice Blue Card(issued by the Commission)Current student identification card issued bya tertiary education institution or school(with photo and signature)Current Qld Gaming Machine LicenceCurrent Qld Licence issued under the Weapons ActNon-Signature DocumentCurrent Medicare cardCurrent Qld crowd controller/privateinvestigator/security officer licencePassbook or account statement issued by abank/building society/credit union dated in thelast 6 monthsAustralian taxation assessment notice dated inthe last 6 monthsThe organisation/volunteer co-ordinator must completePart D.Where the organisation/volunteer co-ordinator is unableto sight the identification documents, a prescribed personmust sight them and complete Parts C and E.Applicant’s NameCCYPCG 04-130 NOV063

PART D Declaration by Organisation/Volunteer Co-ordinator(to be completed by the organisation/volunteer co-ordinator)I declare that:• I am authorised to submit this application on behalf ofthe organisation; and• the volunteer is proposing to undertake regulatedemployment and an exemption does not apply; andPlease tick appropriate box ORI have checked the details provided in thisform and confirm they match those on theidentification documents sighted.I am unable to sight the identification documentsbecause:the volunteer’s usual residence is more than50kms from the business address, orthe volunteer has a disability affecting his orher mobility.Note: It is an offence to provide false or misleadinginformation to the Commission.Full NameSignaturePositionDate / /DAY MONTH YEARPART E Declaration by Prescribed Person(to be completed by a prescribed person)I declare I have checked the details provided in thisform and confirm they match those on the identificationdocuments sighted.Note: It is an offence to provide false or misleadinginformation to the Commission.I am a:Justice of the PeaceCommissioner forDeclarationsLawyerPolice OfficerStamp or Registration No.(if applicable)About the information you giveThe Commission is authorised to collect informationprovided in this form under the Commission for Childrenand Young People and Child Guardian Act 2000.The information will be used to obtain relevant policeinformation held by the Queensland Police Service andother Police Services in Australia for details, if any, ofcharges, convictions (including findings of guilt or pleasof guilt, whether or not a conviction was recorded) andcertain investigative information.Information may also be provided to relevantdisciplinary bodies to obtain certain disciplinaryinformation.If any relevant record is identified, more informationabout that record may be sought from agencies suchas courts, police, prosecuting authorities and StateReporting Bureaus to enable a full and informedassessment of this application.Information is provided to Queensland Police Serviceto monitor blue card compliance and for policeinvestigations relevant to the harm of children.It may also be disclosed to other relevant people ororganisations as authorised under the Act.An applicant may withdraw their consent to screeningat any time before a decision is made about theirapplication.The Commission may publish a register of valid, lost orstolen blue card numbers on its website.The use of this information is covered by theconfidentiality provisions of the Commission for Childrenand Young People and Child Guardian Act 2000 and theprinciples of the Commission’s Privacy Policy availableat: www.bluecard.qld.gov.auCommission for Children and Young Peopleand Child GuardianLevel 14, T & G Building141 Queen StreetBrisbane Qld 4000PO Box 12671Brisbane George Street Qld 4003Phone: 07 3247 5145Toll-free: 1800 113 611Fax: 07 3247 5200Website: www.bluecard.qld.gov.auNote: applications for volunteers areprocessed free of charge.SignatureFull NameDate/ /DAY MONTH YEAR4Applicant’s NameCCYPCG 04-130 NOV06