Carers Application Form

02 6626 3700

PO Box 580
Lismore NSW 2480

PLEASE NOTE:
All Carer Applicants, as well as any additional household members over the age of 18 listed on the application, must have a current Working With Children Check (WWCC).

Before proceeding, complete any applications at:
https://www.kidsguardian.nsw.gov.au/child-safe-organisations/working-with-children-check

When you receive your WWCC, please attach it in the area below.

Thank you again for your interest in becoming a carer.

APPLICANT 1
SURNAME*
GIVEN NAMES*
OTHER NAME/S
DATE OF BIRTH*
Date Format: MM slash DD slash YYYY
ADDRESS*
Street Address City State Postcode Country
PHONE*
MOBILE
EMAIL*
Enter Email Confirm Email
CULTURAL BACKGROUND*
OCCUPATION*
RELATIONSHIP TO APPLICANT 2 (IF ANY)
PREFERRED MAIL METHOD*
- POSTAGE
- EMAIL
APPLICANT 2
SURNAME
GIVEN NAMES
OTHER NAME/S
DATE OF BIRTH
Date Format: MM slash DD slash YYYY
ADDRESS
Street Address City State Postcode Country
PHONE
MOBILE
EMAIL
Enter Email Confirm Email
CULTURAL BACKGROUND
OCCUPATION
RELATIONSHIP TO APPLICANT 1 (IF ANY)
PREFERRED MAIL METHOD
- POSTAGE
- EMAIL
OTHER PEOPLE WHO LIVE IN YOUR HOME
This includes all adult household members and children who reside at the premises for a period of 21 days or more. PLEASE NOTE: any household member over the age of 16 years will require a National Criminal Records Check and over the age of 18 years will also requires a NSW Working with Children Clearance.
NAME RELATIONSHIP GENDER DATE OF BIRTH WORKING WITH CHILDEN CHECK CURRENT? (YES/NO)
NAME RELATIONSHIP GENDER DATE OF BIRTH WORKING WITH CHILDEN CHECK CURRENT? (YES/NO)
NAME RELATIONSHIP GENDER DATE OF BIRTH WORKING WITH CHILDEN CHECK CURRENT? (YES/NO)
NAME RELATIONSHIP GENDER DATE OF BIRTH WORKING WITH CHILDEN CHECK CURRENT? (YES/NO)
NAME RELATIONSHIP GENDER DATE OF BIRTH WORKING WITH CHILDEN CHECK CURRENT? (YES/NO)
MOTIVATION AND REASON FOR CARING FOR A CHILD IN CARE*
EXPERIENCE IN CARING FOR CHILDREN AND YOUNG PEOPLE*
KNOWLEDGE AND CONNECTION TO THE ABORIGINAL AND TORRES STRAIT ISLANNDER COMMUNITIES*
PLEASE DESCRIBE YOUR HOME ENVIROMENT*
HOW MANY BEDROOMS IN YOUR HOME?
DO YOU OWN YOUR HOME OR RENT PRIVATELY?*
- OWN
- RENT
DO YOU LIVE IN A RURAL OR RESIDENTIAL AREA?
DO YOU HAVE A SWIMMING POOL OR DAM?
IF YOU DO HAVE A POOL, PLEASE PROVIDE A COPY OF YOUR POOL REGISTRATION CERTIFICATE AND POOL COMPLIANCE CERTIFICATE.
POOL CERTIFICATES
Drop files here or
EMPLOYMENT
APPLICANT 1
ARE YOU CURRENTLY EMPLOYED?
- YES
- NO
IF YES, PLEASE PROVIDE EMPLOYMENT DETAILS AND HOURS OF WORK PER WEEK
APPLICANT 2
ARE YOU CURRENTLY EMPLOYED?
- YES
- NO
IF YES, PLEASE PROVIDE EMPLOYMENT DETAILS AND HOURS OF WORK PER WEEK
TRANSPORT
DO YOU HAVE CURRENT DRIVERS LICENSE?
- YES
- NO
IF YES PLEASE PROVIDE LICENSE NUMBER
APPLICANT 1
APPLICANT 2
ARE YOU CLOSE TO PUBLIC TRANSPORT?
- YES
- NO
HEALTH STATUS
PLEASE NOTE THAT POTENTIAL CARERS ARE NOW REQUIRED TO COMPLETE THE CARER MEDICAL QUESTIONAIRE
HAVE YOU HAD A MEDICAL HEALTH CHECK IN THE LAST 12 MONTHS?
APPLICANT 1
- YES
- NO
APPLICANT 2
- YES
- NO
PLEASE NOTE IF YES, YOU WILL BE ASKED TO PROVIDE A COPY TO THE NGUNYA JARJUM CARE TEAM
REFERENCES
PLEASE GIVE THE NAMES OF TWO PEOPLE THAT CAN GIVE YOU A REFERENCE AND AREN'T RELATED TO YOU. ONE OF THE REFERENCES MUST BE ABORIGINAL OR TORRES STRAIT ISLANDER (ATSI) AND ACKNOWLEDGED. IF THROUGHOUT THEIR COMMUNITY. IF 2 APPLICANTS, REFERENCES CAN INDICATE THEY RELATE TO BOTH APPLICANTS.
REFERENCE 1
NAME CONTACT DETAILS RELATIONSHIP
REFERENCE 2
NAME CONTACT DETAILS RELATIONSHIP
TYPE OF CARERS REQUIRED
NGUNYA JARJUM PROVIDES CARE FOR A RANGE OF CHILDREN AND YOUNG PEOPLE TO THE AGE OF 18 OUR CHILDREN AND YOUNG PEOPLE REQUIRE VARIOUS TYPES OF CARE.
TYPE OF CARE
- Select All
- SHORT TERM
- LONG TERM
- CRISIS/EMERGENCY
- RESPITE 0 - 4 YRS
- RESPITE 5 - 13 YRS
- RESPITE 14 - 17 YRS
ARE YOU WILLING TO DISCUSS CARING FOR A CHILD WITH HIGH NEEDS?
NGUNYA JARJUM ALSO PROVIDED CARE FOR A RANGE OF HIGH NEEDS CHILDREN AND YOUNG PEOPLE THESE INCLUDE CHILDREN AND YOUNG PEOPLE WITH BEHAVIOURAL, MEDICAL AND A RANGE OF OTHER NEEDS.
- YES
- NO
WORKING WITH CHILDEN CHECKS*
PLEASE UPLOAD ALL CURRENT WWCCs HERE
Drop files here or
FURTHER COMMENTS?
AGREEMENT*
I HEREBY PROVIDE CONSENT TO NGUNYA JARJUM TO UNDERTAKE THE NECESSARY COMPLIANCE AND SAFETY CHECKS IN ACCORDANCE WITH LEGISLATIVE REQUIREMENTS AND THE NSW CARERS REGISTER. THESE CHECKS INCLUDE NATIONAL CRIMINAL HISTORY CHECK, WORKING WITH CHILDREN CHECK AND FACS CHECK.
I / WE AGREE THAT I / WE HAVE NOT PROVIDED ANY FALSE OR MISLEADING INFORMATION. THIS INCLUDES DETAILS / CHECKS ON ADULT HOUSEHOLD MEMBERS WHO ARE RESIDING IN THE HOME AND REFERENCE CHECKS.
APPLICANT 1*
FULL NAME DATE
APPLICANT 2
FULL NAME DATE
Email
This field is for validation purposes and should be left unchanged.

02 6626 3700

Carers Application Form

APPLICANT 1

APPLICANT 2

OTHER PEOPLE WHO LIVE IN YOUR HOME

EMPLOYMENT

TRANSPORT

HEALTH STATUS

REFERENCES

TYPE OF CARERS REQUIRED

Acknowlegement

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