Name Address Home Phone Mobile Phone Work Phone Your email Your Interests FundraisingEventsMarketingWebsite DesignPhotographyCookingMediaSupervisingLobbying Driver's Licence YesNo First Aid Qualifications Your preferred way to contribute Dee Why Cafe (Wednesday)Balgowlah Cafe (Saturday)Be a donation collector Please inform us if there is any information we should know that is pertinent to your involvement with Street Mission (e.g. health issues) By completing this application, I agree that I will maintain at all times the confidentiality of all privileged or proprietary information to which I am exposed while working as a Street Mission volunteer, whether this information involves a client, another volunteer or other person, or involves overall Street Mission business. REFEREES: Please give the names and contact phone numbers of persons we can contact as a personal referee for you (not immediate family). 1. Referee Name Phone 2. Referee Name Phone EMERGENCY CONTACT: Please give the names and contact phone numbers of persons who we should contact in the event of an emergency. 1. Contact Name Phone 2. Contact Name Phone Where did you hear about Street Mission ? PROHIBITED EMPLOYMENT DECLARATION BACKGROUND The Commission for Children and Young People Act 1998 makes it an offence for a prohibited person (as person convicted of a serious sex offence, the murder of a child or a child-related personal violence offence, as well as a Registrable person under the Child Protection (Offenders Registration) Act 2000) to apply for or otherwise attempt to obtain, undertake or remain in, child-related employment. For further information on what is child-related employment, see the Working with Children Employer Guidelines. Section 33B of the Commission for Children and Young People Act 1998 defines a serious sex offence as: an offence, involving sexual activity or acts of indecency, committed in New South Wales and that was punishable by penal servitude or imprisonment for 12 months or more; or an offence, involving sexual activity or acts of indecency, committed elsewhere and that would have been an offence punishable by penal servitude or imprisonment for 12 months or more, if it had been committed in New South Wales; or an offence under Section 80D or 80E (sexual servitude) of the Crimes Act 1900, committed against a child; or an offence under Sections 91D-91G (child prostitution, other than if committed by a child prostitute) of the Crimes Act 1900 or a similar offence under a law other than a law of New South Wales; or an offence under Section 91H, 578B or 578C (2A) (child pornography) of the Crimes Act 1900 or a similar offence under a law other than a law of New South Wales; or an offence of attempting, or of conspiracy or incitement, to commit an offence referred to in the preceding paragraphs; or any other offence, whether under the law of New South Wales or elsewhere, prescribed by the regulations. NOTE: A conviction for carnal knowledge is classified as a serious sex offence under this legislation. Section 33B of the Commission for Children and Young People Act 1998 defines a child-related personal violence offence as an offence committed by an adult: involving intentionally wounding or causing grievous bodily harm to a child; or of attempting, or of conspiracy or incitement, to commit such an offence. Under Commission for Children and Young People Act 1998: it is an offence for a prohibited person to apply for or otherwise attempt to obtain, undertake or remain in child-related employment; employers must ask existing employees, both paid and unpaid, and preferred applicants for child-related employment to declare if they are a prohibited person or not; all people in child-related employment must inform their employers if they are a prohibited person or remove themselves from child-related employment; and penalties are imposed for non-compliance. I am aware that I am ineligible to apply for or otherwise attempt to obtain, undertake or remain in, child-related employment if I have been convicted of a serious sex offence or child-related personal violence offence as defined in the Commission for Children and Young People Act 1998, or if I am a Registrable Person under the Child Protection (Offenders Registration) Act 2000. I have read and understand the above information in relation to the Commission for Children and Young People Act 1998. I am aware that it is an offence to make a false statement on this form. I consent to a check of my relevant criminal records, to verify the statement I have made here, being undertaken by the NSW Commission for Children and Young People for monitoring and auditing purposes in accordance with Section 36 (1)(f) of the Commission for Children and Young People Act 1998. I declare that I am not a person prohibited by the Act from seeking, obtaining, undertaking or remaining in childrelated employment. I understand that this information and other contact provided to Street Mission may be referred to the Commission for Children and Young People and/or to NSW Police for law enforcement purposes and for monitoring and auditing compliance with the procedures and standards for the Working With Children Check in accordance with Section 36 (1)(f) of the Commission for Children and Young People Act 1998. Name: Aliases (previous/other names): Date of Birth: NOTE: Seek legal advice if you are unsure of your status as a prohibited person. I confirm the above declaration.
