Volunteer Application - St John Ambulance ACT

Personal Particulars - Step 1 of 4

Title

Name *

First

Last

Preferred name

Date of Birth

Sex

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Mobile *

Home Phone

Email *

Photo Identification

You will be required to show this when you come for an induction.

Document Type *

Number *

Issued by *

Expiry Date (if applicable)

Next of Kin

Name *

Phone *

Relationship *

Declaration of Pre-existing Injury/Illness

If 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 Conduct

Workplace Harassment and Bullying Policy *

I have read and understand the St John Ambulance Australia Workplace Harassment and Bullying Policy

Child Protection Policy *

I have read and understand the St John Ambulance Australia Child Protection Policy

I have read and understand the St John Ambulance Australia Privacy Policy

Signature *

Phone

Photo Identification

Next of Kin

Qualifications and Training

National Police Check Form

Working With Vulnerable People Card