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Peer Support Volunteer Application
Peer Support Volunteer Application
Contact Info
First Name
*
Last Name
*
*
Email
*
*
*
Contact Number
*
Street 1
*
Street 2
*
Suburb
*
State
*
Postcode
*
Aboriginal or Torres Straight Islander origin
Gender
Male
Female
Not specified
Date of Birth
*
Employment Status
Employed
Unemployed
Part Time
Retired
Caring for Children
Student
Languages Spoken
*
Current or previous occupation
*
Course of Study
*
How did you hear about us?
*
Social media eg Facebook, Instagram
Website search
Media eg radio, newspaper, television
From a friend
From my healthcare provider
Word of mouth
Volunteer Profile
Volunteer Contact
About your amputation
Reason for your amputation
Birth
Cancer
Diabetes
Infection
Trauma
Vascular disease
Other
Reason for amputation - more information
*
Lower appendage
Toes
Partial Foot
Foot/Symes
Below Knee
Through Knee
Above Knee
Hemipelvectomy
Bilateral Below
Bilateral upper/lower
Lower appendage Other Information
*
Upper appendage
Fingers
Partial hand
Hand
Below Elbow
Above Elbow
Bilateral
Upper appendage other information
*
Year of Amputation
*
*
Why are you interested in becoming a Volunteer ?
*
What do you think you have to offer as a Volunteer?
*
Do you volunteer for other community, sporting or government orgs?
*
List other forms of Voluntary support you are willing to offer
*
Do you have access to a vehicle which can be used?
Do you have access to a vehicle which can be used?
No
Do you have access to a vehicle which can be used?
Yes
How far from home are you willing to travel (eg 5 kms)
*
*
How will you travel to Support Visits
*
Additional Information
Emergency Contact First Name
*
Emergency Contact Last Name
*
Relationship to you
*
Contact's phone number
*
Referree
Referree Contact First Name
*
Referree Contact Last Name
*
Relationship to you
*
Contact's phone number
*
Please tick applicable
I am willing to attend an interview
I am willing to undergo a national police check
I am willing to undertake Peer Support Volunteer training
I am willing to adhere to Limbs 4 Life policies and procedures
I am willing to receive direction from Limbs 4 Life staff
I can offer other forms of voluntary support
I agree to Limbs 4 Life terms and conditions
For more information about Limbs 4 Life’s Term and Conditions please click
here
.
To view Limbs 4 Life’s privacy policy please click
here
.
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