VOLUNTEER APPLICATION FORM
UNDER 18
Interchange Gippsland provide respite and support to children and young adults with disabilities across
Gippsland. Our volunteer program provides experiences for the young people on our programs by
enhancing their lives with new opportunities. Young volunteers (under 18) generally work on our recreation
programs for participants aged 10 – 17 years which are offered across the local government areas of
Latrobe City, Baw Baw, South Gippsland and Bass Coast Shire. The role of young volunteers is to be a peer
support and encourage participation in activities.
Volunteering commitments can be as little or great as you like. You can assist on range of programs from
day trips to overnight camps. Invitations are sent out for each trip and you reply to Administration if you are
available to volunteer.
Volunteering with Interchange Gippsland is very rewarding and provides families with invaluable support
and time out from their caring role. As our Volunteer you are provided with support, training and
development. During our trips volunteers are supported by a team of professionally trained and
experienced Support Staff.
Interchange Gippsland is a ‘Child Safe’ organisation. We are committed to the safety and wellbeing of all
children and young people accessing our service and support the rights of the child. We will act without
hesitation to ensure that a child safe environment is maintained at all times. We adhere to Child Safe
standards in the development and production of all our promotional material and newsletters, recruitment
documents (including advertisements and application forms) and in electronic communication media
involving our internet, intranet and social media pages. All Support Workers, Adult Volunteers and Young
Volunteers on our program must have satisfactorily completed the screening procedures.
Privacy Notice
Interchange Gippsland is collecting the personal information requested in this form in order to:
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obtain lawful consent for your child to participate in the volunteering activity;
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help coordinate the activity;
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respond to any injury or medical condition that may arise during, or as a result of the activity; and
The information will only be accessed by Interchange Gippsland staff and will be dealt with in accordance with the
confidentiality requirements of the Privacy Act. The information will not be disclosed to any other person or agency
unless it is for a purpose stated above or the disclosure is authorised or required by law
Please complete all sections of this registration form
Name
Address
Town:
Telephone
Postcode:
Home :
D.O.B
Email
Parent/Guardian
Name(s)
Parent Guardian Contact
Number(s):
Parent/Guardian Email
School Attending
Mobile:
Volunteering Interests
I am interested in attending the following activities as a Volunteer with Interchange Gippsland:
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Weekend Day Trips AVAILABLE  Saturday  Sunday  Both days
Weekend Camps
School holiday day trips
School holiday camps
Referee Details
Volunteers are required to submit a minimum of one referee. Examples of suitable referees are
teacher, part time job boss, sports coach (they cannot be a family member). We will contact your
referee to ensure you are responsible and suitable to be volunteering with Interchange
Gippsland.
Referee 1 Name:
Referee 1 Contact Number:
Relationship to referee:
Referee 2 Name:
Referee 2 Contact Number:
Relationship to referee:
Skills/Qualifications
Do you have any skills or qualifications that might be relevant to your volunteering:
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Play Sport Details _____________________________________________________________
Play a musical instrument: Details _______________________________________________
Sing
Artistic
Coach or umpire sport Details ___________________________________________________
Bronze Medallion/Life Guard qualification
Drama
Other
Details ________________________________________________________________
On Call Consent
Interchange Gippsland provides your personal details to Latrobe Community Heath Service who
act as our after hours on call service provider. This is done exclusively for the purpose of
providing an emergency on call service for our activities operating outside normal business hours
that your child is participating in as a volunteer with Interchange Gippsland.
Insurance
Please note that Interchange Gippsland has personal accident insurance cover for volunteers.
Interchange Gippsland Under 18 Volunteer Application Form
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Photographic Permission – to be completed by parent/guardian
Interchange Gippsland needs your written permission to use your photograph in publicity
regardless of age.
I hereby authorise Interchange Gippsland to use any photograph that I/my child appear in for use
in the following circumstances
AREAS
Please tick the boxes
YES
NO
Interchange Gippsland Website
Interchange Gippsland Facebook Page
Interchange Gippsland Brochures
Interchange Gippsland Facebook page
Newspapers
Promotional Display Material
Television appearance
My permission extends for the period specified below
Open ended as long as the photograph is used in context of promoting Interchange
Gippsland and its activities
Only while my family member is a volunteer with Interchange Gippsland
Other (please specify)
OR
I do not give permission for photographs for my child to be used in any circumstances
as an Interchange Gippsland volunteer
Medical Details
Medical Details - Please list any relevant medical or physical conditions
NOTE: Please disclose all pre-existing injuries, diseases or conditions of which you are aware that could affect your ability to carry out
the proposed volunteer role. Please note that if you provide a false or misleading disclosure or fail to disclose, you will not be entitled
to compensation in certain circumstance including the recurrence, aggravation, acceleration, exacerbation or deterioration of a preexisting injury
Allergies:
Regular Medications:
Interchange Gippsland Under 18 Volunteer Application Form
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Parent/Guardian Authorisation and consent
Please complete the required information and check all appropriate boxes below to indicate your
agreement/consent for your child to become a volunteer with Interchange Gippsland:
I ___________________________ as the parent/guardian of ______________________________
YOUR NAME
VOLUNTEERS FULL NAME
declare that the information provided on this form is true and correct. By signing this
authorisation and consent I provide permission for my child to participate in Interchange
Gippsland Teenage Volunteer program and have checked and agree to the statements below:
I have read all of the information contained in this form in relation to the volunteer activity my child
will be undertaking with Interchange Gippsland.
I give consent for my child, _______________________________________________ (print child’s
name), to participate as a volunteer with Interchange Gippsland.
I understand that in providing permission for my child to undertake a volunteer role with
Interchange Gippsland I am also accepting that my child’s emergency details including our
families contact details, emergency contacts and relevant medical information regarding my child
will be shared with Latrobe Community Health Service as Interchange Gippsland’s emergency on
call after hours service.
I have provided Interchange Gippsland with all relevant details relating to my child’s medical or
physical needs
In the event of an accident or illness, I authorise Interchange Gippsland staff to obtain or
administer any medical assistance or treatment my child may reasonably require.
Parent/Guardian Name:__________________________________________________(Please Print)
Parent/Guardian Signature: ______________________________ Date: ______/_______/______
Volunteer Applicant Name: _______________________________________________(Please Print)
Volunteer Applicant Signature: _______________________________ Date: _____/______/_____
OFFICE USE ONLY
---------------------------------------------------------------------------------Received by Interchange Gippsland: ____________________________ Date _____/_____/_____
Reference Checks Complete: __________________________________ Date _____/_____/_____
Inputted in TCM: --____________________________________________ Date _____/_____/_____
www.icg.asn.au
 1300 736 765
[email protected]
All Correspondence to Manager Marketing and Communications
PO BOX 303, MOE, 3825
Servicing Gippsland with Offices in Newborough and Wonthaggi
Interchange Gippsland Under 18 Volunteer Application Form
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