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Office Use Only:

Application form
received ____________

Acknowledgment letter
sent ________________

VOLUNTEER APPLICATION FORM


Please tick preferred hospital

PMH Fremantle Joondalup Armadale Murdoch

Selection for interview will be made only from applications that have been completed in
full. Please complete the application form and return it to Radio Lollipop at the address
provided on page 5.

Radio Lollipop (Aus) Ltd. is committed to equal opportunities at all stages of the
recruitment process. If you have difficulty in completing this application form because of
disablement the form can be completed by another person, however it must be signed by
you and made clear that it has been completed on your behalf.

SECTION 1 PERSONAL DETAILS

Mr/Mrs/Ms/Miss First Name Last Name


Address Post code
Telephone: Home Work Mobile
E-mail Address
Occupation
Are you over 18 years of age Yes No

Do you have a current driving licence? YES NO

SECTION 2 EDUCATION

Please provide details of all institutions attended and qualifications attained, including
certificates, diplomas or degrees.

School/College/University Qualification Years Enrolled Date Received

______________________ ____________ _____________ _______________________


______________________ ____________ _____________ _______________________
______________________ ____________ _____________ _______________________
______________________ ____________ _____________ _______________________
______________________ ____________ _____________ _______________________

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Please provide details of any other education or training you have undertaken (including
non- examination courses).
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

SECTION 3 PRESENT / MOST RECENT EMPLOYMENT

Employer’s Position Held Brief Outline of Date Reason for


Name and Duties From: Leaving
Address To:

______________ ____________ ________________ ___________ ______________


______________ ____________ ________________ ___________ ______________
______________ ____________ ________________ ___________ ______________
______________ ____________ ________________ ___________ ______________

SECTION 4 REASON FOR APPLICATION


This section must be completed in full. Please attach any additional sheets if more space is
required.

Please provide reasons with supporting statements for your application to Radio Lollipop.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

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How did you hear about Radio Lollipop?

Have you ever been involved in Radio Lollipop in any way previously? If so, how and
when.

Why are you interested in becoming a volunteer with Radio Lollipop?

What experience/s have you had with children (including your own)? Please include any
other experience/s you feel relevant.

______
________________________________________________________________________
What other voluntary experience(s), if any, have you had?

Are you prepared to devote a minimum of two hours ward visiting per week quarterly
(10 out of 13 weeks)? This is an essential requirement to being a Radio Lollipop volunteer.
Yes No

SECTION 5 REFERENCES AND SECURITY SCREENING

Please give details of two professional people who can act as a referee for you, and state
their relationship to you. We will contact them regarding your application should you be
offered an interview.
Name Name
Relationship to you Relationship to you
Occupation Occupation
Address Address

Telephone: (Home) Telephone: (Home)


(Work) (Work)

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Radio Lollipop Volunteers work with children in the hospital environment and in a
position of trust. To comply with the regulations of the Health Department of Western
Australia, it is necessary to ask you to disclose any information concerning any convictions.
All information given in this respect will be completely confidential and will only be
considered in relation to this application. Failure to disclose any such information will
result in termination of your services to Radio Lollipop.

If your application is successful we will carry out a Federal Police Clearance.

Do you have any convictions for an offence or offences? Yes No

Are you currently the subject of any charge pending before any Court? Yes No

If the answer is yes to either question, please give details and the dates.
_____________________________________________________________________________
_____________________________________________________________________________
__________________________________________________________________________

SECTION 6 DATA PROTECTION ACT XXX

I understand that the information provided on this form will be used to enable a personal
file of
__________________________________ and/or computerised file to be established.
(Please print your full name)

Signed: _______________________ Date: __________________________

SECTION 7 DECLARATION
Please ensure you complete all questions asked on this part of the form and sign below.
I declare that the information provided in this application form is true and correct. I
understand any attempt to mislead or provide false information will result in an
unsuccessful application. I understand that providing any false information may lead to the
withdrawal of any offer of a volunteering position with Radio Lollipop, or the termination
of a future volunteering role with Radio Lollipop.

Signed: ___________________________________

Date: _____________________________________

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Prior to Posting, please tick off the following list:
Read and understood information sheet
Completed all fields in the Application Form (incomplete forms will not be processed
and no notification will be forthcoming)
Provided two professional referees
Signed and dated all applicable areas of the Application Form

Thank you for completing this application form, please post it and a copy of your resume
(if available) to:

Honorary Volunteer Co-ordinator Radio Lollipop


Princess Margaret Hospital
GPO Box D184
Perth WA 6840

Phone: 9340 8835


Fax: 9381 3355