Lane Cove Community Aid Service

164 Longueville Road Lane Cove 2066
(Ph.) 9427 6425 (Fax) 9427 793

email: volunteers@lccas.com

Volunteer Information Form
Confidential

Surname
Given Names
Address
  Post Code
Telephone     Mobile
Email        
           
Drivers Licence Number (if applicable)     Registration Number
Vehicle Comprehensive Insurance          
Company Name     Policy Number
           
Times Available   Weekly     Fortnightly    
    Monthly    Emergency    
           
Monday Tuesday Wednesday Thursday Friday Saturday
           
Volunteer Work Desired          
  Meals on Wheels: Driver / Helper   Community Support Transport
  Help with Social Activities   Linen Service
  Community Visitors Scheme   Office Assistance
  Shopping Service   Gardening Service
           
Skills - Hobbies - Languages
           
Previous Experience (paid or unpaid)
           
Are you currently:          
Employed   Full Time Part Time  
Student          
Retired          
Seeking Work          
Receiving any form of compensation payment: Yes   No  
           
Are there any health issues/disabilities/courses or treatment/allergies which might prevent you from performing volunteer duties assigned to you?
    Yes   No  
If Yes, please state:
           
Referee 1 - personal Name
  Address
   
  Day Phone Number
     
Referee 2 - professional Name
  Address
   
  Day Phone Number
           
In Case of Emergency Please Contact:
  Name
  Address
   
  Day Phone Number
  Relationship
    OR
  Name
  Address
   
  Day Phone Number
  Relationship
           
I am willing to have a police check: Yes   No  
           

The above Information is true and correct to the best of my knowledge. I understand that the position I am applying for is a volunteer position and that there is no financial remuneration for my services. I understand that some "out of pocket" expenses will be re-imbursed. This should be discussed with the program coordinator prior to commencement of service.

Management reserves the right to refuse placement of a volunteer. Check this to agree.
           
Volunteer Name     Date
Interviewd By:     Date
How did you hear about us?
Brochure      Banner      Press     Word of Mouth     Website