Please enable JavaScript in your browser to complete this form.Personal Particulars - Step 1 of 4TitleDrMrMrsMsMissName *FirstLastPreferred nameDate of BirthSexMaleFemalePrefer not to sayAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryMobile *Home PhoneEmail *Photo IdentificationYou will be required to show this when you come for an induction.Document Type *Number *Issued by *Expiry Date (if applicable)Next of KinName *Phone *Relationship *NextWhy do you wish to join St John Ambulance ACT? *What skills and attributes do you possess that would contribute to SJA and working within a team? *Go beyond your physical skills and be sure to include interpersonal attributes as well!What area of St John Ambulance ACT do you want to get involved in? *Event Health ServicesCBR NightCrewCommunity EducationUnique Student Identifier (USI) *This is required for all accredited training, if you don't have one visit https://www.usi.gov.au/Previous St John service (if any)Please include state/country and time period.Qualifications and TrainingTo be a St John Ambulance member you must have a minimum of Provide First Aid (HLTAID003) and Provide CPR (HTLAID001) completed within the last 12 months.Qualification 1 *Issued by *Expiry Date *Qualification 2Issued byExpiry DateQualification 3Issued byExpiry DateQualification 4Issued byExpiry DatePreviousNextDeclaration of Pre-existing Injury/IllnessIf you have any physical or mental health injury or illness please provide details and dates. Please note that if your membership as a St John ACT volunteer is successful, you may be required to provide a medical clearance to the organisation. Furthermore, at any time during your membership as a St John ACT volunteer, if it becomes apparent, or there is reason to believe, that you are unable to safely and effectively perform the duties and requirements of the position, a ‘Review of Ability’ by a medical practitioner may be required.Declaration of ability *I have read the Declaration of Ability and am able to fulfil the requirements for first aid duties.I understand that, as a member of St John Ambulance Australia (ACT) Event First Aid, I may be required to perform a variety of tasks and duties and assume responsibilities including those listed below: 1. To perform first aid duties in a variety of circumstances. This may include emergencies and other stressful situations. 2. To communicate orally with casualties, fellow workers and the public, including for the gaining of information that will assist in completing a Patient Report form (previously OB12). 3. To be fit enough to perform effective one-person adult Cardiopulmonary Resuscitation on the floor for 5 minutes. This ability will be assessed annually. 4. To carry first aid and other emergency apparatus (potentially weighing up to twenty kilograms) to a casualty in order to administer first aid in a timely manner. 5. To assist in lifting and moving a casualty for a reasonable distance. This may include being assisted by one or more people and/or utilising a stretcher. 6. To work as part of a team and accept and follow directions. 7. To undertake study programs, participate in gaining and developing the knowledge and skills relating to first aid and use the knowledge and skills acquired from such study programs. 8. To remain within my scope of practice. This includes recognising the limits of first aid and my abilities and be ready to ask for help. 9. To take precautions for my safety and those for whom I am caring, including maintenance of personal immunisation status and carrying out of protective measures (e.g. wear protective gloves) consistent with the duties to be performed. 10. To aim for at least 60 hours of service at events during the reporting period. I acknowledge that: • a false or misleading statement could lead to review of my suitability as a St John ACT volunteer • there are health risks associated with smoking, excess alcohol intake and the use of illicit drugs. These activities may also adversely affect my ability to effectively serve the community; St John Ambulance ACT has a duty to ensure that members allocated to events are able to function safely and effectively.Code of Conduct *I have read and understand the St John Ambulance Australia Code of ConductWorkplace Harassment and Bullying Policy *I have read and understand the St John Ambulance Australia Workplace Harassment and Bullying PolicyChild Protection Policy *I have read and understand the St John Ambulance Australia Child Protection PolicyPrivacy Policy *I have read and understand the St John Ambulance Australia Privacy PolicySignature *Clear SignaturePreviousNextNational Police Check FormAs part of joining St John Ambulance you will need to complete a National Police Check Form.Working With Vulnerable People CardAs part of joining St John Ambulance you will need to attain a Working With Vulnerable People Card.Have you completed he NPC Form?YesNoIf No is selected you will need to provide this completed documentation 2 weeks prior to your induction date.Do you have a WWVP Card?YesNoIf No is selected you will need to provide a copy of your WWVP Card 2 weeks prior to your induction date.National Police Check Form *Please upload the form so that it can be submitted.WWVP Card *Please upload a scanned copy of your WWVP Card. 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