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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
.
Sign me up to the Limbs 4 Life newsletter
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