Guardianship Application Form

17 March 2015

Applicant 1

Applicant 2

First name

First name

Surname

Surname

Previous names (if applicable)

Previous name (if applicable)

Date of Birth

Date of birth

Country of birth

Country of birth

Do you identify as Aboriginal?

Yes

No

Yes

No

Yes

No

Do you identify as Torres Strait Islander?

Yes

No

Home address

Home address

Contact phone

Contact phone

Email

Email

Relationship to child

Relationship to child

Religion

Religion

Cultural Background

Cultural background

Do you speak any other language other than English?

Yes

No

Yes

No

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17 March 2015
Language spoken

Language spoken

Work Details
Occupation

Occupation

Number of hours worked per week

Number of hours worked per week

Are you employed by the Department of Family and Community Services (FACS)?
Yes

No

Yes

Details

No

Details

Note:

If you are employed by FACS, please discuss your application with your supervisor.

Do you receive a fortnightly Centrelink payment?

Yes

No

Yes

Details

No

Details

Household
Name

Date of
Birth

Cultural
Heritage

Relationship to
Applicant 1

Relationship to Applicant 2

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17 March 2015
Do you have children under the age of 18 years residing
away from home?
Name

Age

Location

Yes

No

Reason

Interest in Guardianship
Have you or your partner previously been, or applied to become a
foster, relative or kinship carer or adoptive parent in Australia?
If yes, please provide details of the agency you applied to.

Briefly tell us why you are interested in becoming a guardian.

Details

Yes

No

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17 March 2015

Medical Information
Do you have any medical or psychological condition that may affect your ability to provide daily
care for the child or young person until they are at least 18 years of age?
Yes

No

Yes

Details

No

Details

Please provide the name of your doctor that we can contact to obtain information about your health
and well being in relation to becoming a guardian.
Any information they provide will be kept strictly confidential and will not be used for any other purpose.
Doctors name

Doctors name

Phone number

Phone number

Referees
Please provide the names and contact details of two people to act as referees for your application.
These people:
-

are in current contact with you

have known you and your family for at least two years

have observed you interacting with children on a regular basis

are not directly related to you

are willing to provide a reference if required.

Referees name

Referees name

Home address

Home address

Phone number

Phone number

Email

Email

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17 March 2015

Checklist and Consent

I/we have been provided an information sheet about becoming a guardian and the
assessment process

I/we understand that we will be required to provide information that will be needed in
determining my/our suitability in becoming a guardian.

I/we understand that as part of the guardianship assessment process, I/we are
required to undergo suitability checks, including
i.

nationwide criminal record check

ii.

check of Community Services records

iii.

check if a designated OOHC agency or an accredited adoption service

provider has information about me/us.

I/we consent to these checks being undertaken by the Department of Family and
Community Services.
I/we understand I/we must complete the two stage application process for a Working
with Children Check (Child Protection [Working with Children] Act 2012) before I/we
can be provisionally authorised. I/we also understand that I/we cannot be fully
authorised without a Working with Children Check clearance.

To obtain the Working with Children Check application online and in person, visit a
local Roads and Maritime Service or Service NSW registry with proof of identify.

I/we understand that lawful enquiries may be made as it considers appropriate any
check relating to my/our employment or other activities.

I/we consent to the release of medical information held by my/our doctor.

I/we understand that I/we will be required to provide a statement as to my/our physical
health and psychological or mental health.

This is done by completing the FACS Health Checklist for Guardians form.
I/we understand that checks have to be conducted for each additional member of the
household aged 16 years and over. These include:
i.

nationwide criminal record check

ii.

check of Community Services records

iii.

check if an OOHC designated agency or an accredited adoption service

provider has information about me/us.

I/e understand that all adult members of the household aged 16 years and over must
complete the two stage Working with Children Check application, where applicable.
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17 March 2015

I/we understand that a nationwide criminal record check for any household members
aged 14 years and over may be conducted, where applicable.

I/we give permission for the Department of Family and Community Services to contact
other agencies where I/we have previously been a carer.

I/we understand that the information collected will only be used for the purpose of
assessing my/our suitability as guardian and will be treated with the highest degree of
confidentiality.

Applicant 1

Applicant 2

Name

Name

Date

Date

Signature

Signature