(C)
CARING CANINE COMPANIONS(C)
Making a Difference

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VOLUNTEER APPLICATION AND PROFILE

NAME: ____________________________________________________ (Mr, Mrs, Ms, Miss)

ADDRESS: ________________________________________________________________

______________________________________________POSTCODE:__________________

TELEPHONE: ____________________EMAIL:  ___________________________________

AGE GROUP?      UNDER 25       25-39      40-49      50-65      OVER 65

DRIVERS LICENCE?      YES/NO

DO YOU HAVE TRANSPORT?     YES/NO

HOW FAR ARE YOU PREPARED TO TRAVEL?  ______________KMS

OUR VOLUNTEERS ARE ELIGIBLE TO RECEIVE OUT OF POCKET EXPENSES
PLEASE INDICATE YOUR WISHES                                    YES/NO

HAVE YOU EVER DONE VOLUNTEER WORK?                  YES/NO

If Yes    WHERE? ______________________________________________________________

 ____________________________________________________________________________

 WHAT KIND?_________________________________________________________________

  ____________________________________________________________________________

 ARE YOU WILLING TO VISIT  WEEKLY OR FORTNIGHTLY____________________________

WHICH DAYS OF THE WEEK SUIT YOU BEST?     ___________________________________

MORNING OR AFTERNOON?     ______________
(VISITS ARE USUALLY FOR AN HOUR’S DURATION).

 DO YOU HAVE ANY LIMITATIONS TO VOLUNTEERING (e.g. health, work, family
commitments, study  etc)

 ______________________________________________________________________________

DO YOU SPEAK ANY FOREIGN LANGUAGES?                          YES/NO

If  YES, please list _______________________________________________________________

WHAT CONTACT HAVE YOU HAD WITH AGED PEOPLE?  ______________________________

 _______________________________________________________________________________

________________________________________________________________________________

HAVE YOU HAD ANY ASSOCIATION WITH AGED CARE NURSING HOMES?

_______________________________________________________________________________

HAVE YOU EVER BEEN IN THE NURSING PROFESSION?         YES/NO
HAVE YOU HAD ANY CONTACT WITH DEMENTIA?                   YES/NO

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YOUR CANINE COMPANION

 NAME/s:  _____________________________________________________________________________

BREED/s: ____________________________________________________________________________

OBEDIENCE TRAINED?                YES/NO

WELL BEHAVED?                        YES/NO

LIKES PEOPLE?                         YES/NO

ANY OTHER COMMENTS______________________________________________________________

 ____________________________________________________________________________________

            DATE: __________________ SIGNATURE:  ____________________________

 It is important that your volunteer work  be an enjoyable experience.
The questions we have asked you
will assist us to ensure your contribution will be the most suitable
and rewarding for all concerned.

When you have completed this application,
please post to
Caring Canine Companions
Reply Paid 83004
Woodside. SA 5244
Freecall 1800 077 722
Fax 8377 0681
Email: ccccvs@chariot.nat.au