Volunteer Application Form

Thank you for expressing interest in volunteering with Ballarat Health Services. Please place an x in the appropriate boxes below Which area would you like to volunteer in?	Base Hospital	The Queen Elizabeth Centre
Residential Aged Care Facilities (10 Sites)	Planned Activity Groups (Day Centres – 3 sites)
Please indicate the type/s of activity you are most interested in:	Patient support and company	Meet and Greet
Driving	Cancer Support
Socialising and assisting with activities	Customer services/sales/fundraising
Admin/project work

Personal Details

Mr	Mrs	Ms	Miss	Dr	Other

Title (please mark box):

First name:	Surname:

Preferred Name:	D.O.B.:

Address:	CITY:

Post Code:	Email:

Phone:	Mobile:

Emergency Contact Details

Name:	Contact Phone Number:

Address:

Relationship to you (e.g. Friend, partner):

Experience and Qualifications

Please list your qualifications, work experience and special skills (please attach a brief resume if you have one):

Please list any previous or current volunteer experience:

Why do you wish to become a Volunteer at Ballarat Health Services?

Referees

Please supply names and contact details for 2 referees: (people who know you well enough to comment on your character, preferably not friends or family):

Name:

Position / Organisation:

Phone No.:	Email

Name:

Position / Organisation:

Phone No.:	Email

I consent to having my photo taken at any time, to be used by Ballarat Health Services for marketing, promotion and reporting purposes.

Applicant Signature:	Date:	/	/

When complete, please:

Print and post to Volunteer Services, Ballarat Health Services, PO Box 199, Ballarat, 3353

Or save and email to volunteer@bhs.org.au