COACH Mentor Application Form

Please complete this form and submit it to your local Coordinator to initiate your application process prior to your follow up interview.

The reasons why we ask you, as a volunteer, to complete this form and attend an interview are as follows:

It is hoped that the application process will help to increase your awareness and understanding of the role of a mentor and the commitment it requires including the four essential competencies in the mentor position description, in brief:

Being child safe at all times;
Being non-judgemental;
Maintaining the boundaries of the role; and
Having the ability to communicate well with your participant.

It will help the COACH Coordinator to identify strengths and skills which you have to offer and, therefore, assist in matching you to a suitable participant.
It is a screen to assist in exercising due care regarding the welfare of potential participants and to mitigate against harm to potential participants.
It is a mechanism to assist in exercising due care regarding the welfare of any potential mentor.

In addition to completing this form, all potential COACH Mentors will be asked to undertake the following:

Working with Children check (Blue Card Services QLD)
Screening Interview

Applicant's Details

First Name *

Last Name *

Have you been/Are you known by any other names? *

Mobile Number

Email Address

Date of Birth *

Gender *

Marital Status *

Cultural Identity *

Tip: Eg. Aboriginal, Torres Strait Islander, Australian, Indian, Chinese, American etc.

Languages Spoken *

Tip: Identify any languages spoken fluently (incl. English)

Mailing Address *

Mailing Address Line 2

Mailing City *

Mailing State *

Mailing Postcode *

Home Address

Tip: If different from Mailing Address

Home Address Line 2

Home City

Home State

Home Postcode

Dependents

Do you currently have any dependents? *

Yes

Tip: Includes children or other persons who you provide care for.

Dependent 1 Full Name: *

Dependent 1 Year of Birth: *

Dependent 3 Full Name:

Dependent 3 Year of Birth:

Dependent 2 Full Name:

Dependent 2 Year of Birth:

Emergency Contact

Primary Emergency Contact Full Name *

Primary Emergency Contact Phone *

Primary Emergency Contact Email *

Primary Emergency Contact Address *

Primary Emergency Contact Relationship *

Medical Information

Medicare Number *

Private Health Provider (if applicable)

Private Health Member Number

GP Practice Name *

GP Name: *

GP Phone *

GP Practice Address *

Allergies

Other Medical/Relevant Conditions

Tip: Please list anything that may impact your ability to fulfill your voluntary role.

Blue Card & Vulnerable People Declarations

A restricted person is a person who:

has been issued a negative notice, or
has a suspended blue card, or
is a disqualified person, or
has been charged with a disqualifying offence which has not been finalised.

Restricted employment refers to particular exemptions which allow a person to work with children without a blue card, such as:

a volunteer parent;
a volunteer who is under 18;
paid or unpaid staff who work in child regulated employment for not more than 7 days in a calendar year; or
a consumer at a child-related service outlet* where they also carry out work at the outlet.

*A child-related service outlet means a place at which disability services are provided to children.

If you are a restricted person:

you must not start or continue to work in restricted employment.
if you currently work in restricted employment, you must immediately stop or you will be breaking the law and can be prosecuted.
you do not need to tell the organisation the reason why you are no longer able to volunteer or work for them. However, you must immediately stop working or volunteering with the organisation or you will be committing an offence and can be prosecuted.

It is prohibited to start or continue in restricted employment if you are a restricted person. The maximum penalty is $68,925 (500 penalty units) or 5 years in prison. Penalties will also apply to organisations.

Are you a restricted person? *

Yes

Do you hold a current Blue Card Services Working with Children Positive Notice (Blue Card) or Exemption? *

Yes

If you application proceeds, do you consent to Hervey Bay Baptist Church linking your Blue Card? *

Yes

Do you, or have you ever relied on a Blue Card Exemption? *

Yes

Provide details: *

Has you Blue Card ever been suspended for any reason? *

Yes

Provide details: *

Have you ever been the subject of: *

A complaint of harm to a vulnerable person?

A breach of a code of conduct or policy?

A decision to be precluded from attending or participating in a church's/organisation's activities?

None of the above.

Provide details: *

Blue Card Name *

Blue Card Number *

Blue Card Type *

Blue Card Expiry Date *

Have you ever lived or worked overseas for more than 12 months in the past 5 years? *

Yes

Please list countries *

Do you consent to a criminal history check in these countries? *

Yes

Please list all previous involvement in church or community services roles involving vulnerable people (identify which organisation next to the type of work) *

Referees

Referees cannot be related to applicant.

Pastoral Referee (from current church) OR Community Group/Religious Ministry Referee

Full Name *

Phone *

Email (if known)

Relationship *

Address *

Professional Referee

Full Name *

Phone *

Email (if known)

Relationship *

Address *

Personal Referee

Full Name *

Phone *

Email (if known) *

Relationship *

Address *

By signing this form, I authorise COACH and its overarching bodies to obtain any needed information regarding my driving record, legal/criminal history, character references and employment from any state or federal body, my employer, and personal references for the purposes of participating in the mentoring program.

I have read and accepted the COACH Protecting Your Privacy - Mentor statement.

Full Name *

Date *