Please fill in this form and identify any known medical conditions and provide extra information if necessary to ensure your own health and safety during the mentorship program.
What is your preferred pronoun?
Are you Aboriginal and/or Torres Strait Islander?
Is English your preferred language?
EMERGENCY CONTACT INFORMATION
Please provide details on a minimum of 1 emergency contact person including their contact phone number and address.
First Emergency Contact Name
Second Emergency Contact Name
MEDICAL CARE DETAILS
Please complete all details to the best of your ability.
Do you have an ambulance subscription?
Do you hold a healthcare card?
MEDICATION & CONDITIONS
Please provide details of known medical conditions which may affect you and any current or recent medication or treatment that may be relevant. This will be provided to an emergency responder in order to support your specific needs and ensure your safety and wellbeing.
Are you presently taking any medication?
Do you have any known medical conditions (physical and mental health concerns)?
This could include asthma, diabetes, epilepsy, heart disease, anxiety, acquired brain injury, anaphylaxis
Do you have a medical plan for any known medical concerns?
Do you have any known allergies?
This may include to foods, touch and medication.
Some mentoring activities can require a high level of physical exertion including hiking, rowing, abseiling, and camping. It is the advice of Wimmera Southern Mallee LLEN that Volunteers self-assess their level of risk and seek appropriate medical advice to ensure you are fit and able to undertake the activity as planned.
Details of the Mahogany Ship Walk are below. Are you fit and able to undertake this activity?
Distance: 22km /
Duration: 6 hours one way /
Track condition: Sand /
Grade: Gentle /
Start: Thunder Point car park, Warrnambool /
Finish: Griffiths Island car park, Port Fairy /
CONSENT TO TREATMENT - In the event that I am unable to communication and it is impracticable to engage my emergency contact(s), I hereby consent to the person in charge (or their nominee) at the mentoring activity to administer first aid to me, and consent to receiving such medical and surgical treatment (including the administration an anaesthetic) as deemed necessary by a legally qualified medical practitioner. I accept full responsibility for the payment of fees incurred should I require such treatment. I understand that in case of accident or emergency an ambulance will be called and I will be liable for any costs incurred. I give permission for my medical and emergency information to be carried by the mentoring activity coordinator or their nominee. I will immediately alert the program and/or activity coordinator if I begin to feel unwell.
COVID-19 - Individuals thinking of volunteering need to consider issues of covid-19 and self-care and avoid putting themselves and others in the community at risk. This means adhering to recommended social distancing guidelines and other official guidance as it emerges. According to the Australian Government Department of Health website, ‘some people are at greater risk of getting very sick if they contract COVID-19. However, everyone is different. It is important to talk to your doctor if you have a more serious illness or more than one condition’. First Nations people can be at higher risk in any public health emergency. WSMLLEN recommends every volunteer consider the risk factors and talks to their doctor before volunteering if they have a more serious illness or more than one condition. *Volunteer insurance provided by WSMLLEN does not cover serious illness such as Covid-19. WSMLLEN has a duty of care and will ensure Volunteers have access to a suitable level of communication, best practice and prevention information, and up-to-date restriction guidelines. Individuals should only consider volunteering with due consideration to the risk factors involved and may wish to seek independent legal advice. For advice on how to seek medical help or get tested for coronavirus (COVID-19) you can contact the Victorian Department of Health and Human Services, or call the coronavirus (COVID-19) helpline on 1800 020 080 at any time.
PRIVACY - WSMLLEN’s volunteer programs collect and administer a range of personal information for the purpose of operating the programs. It is committed to protecting the privacy of personal information it collects, holds and administers. WSMLLEN recognises the essential right of individuals to have their information administered in ways that they would reasonable expect – protected on one hand and accessible to them on the other. WSMLLEN is bound by Victorian privacy laws, the Information Privacy Act 2000 and other laws which impose specific obligations about handling information. We have adopted the principles contained in the Victorian privacy laws as minimum standards. In broad terms this means that WSMLLEN: Collects only information that is needed to effectively run the volunteer programs; Ensures that all program participants understand why we collect information and how it is administered; Use and disclose personal information only for our primary function or a directly related purpose, or for any other purpose only with the person’s explicit consent; Store personal information securely, protecting it from unauthorised access; Give participants access to their own information and the right to correct it.