Personal Information
Full Name
Address
Postcode
Date of Birth
Email Address
Contact Number
Volunteer Roles
Other Skills
Previous Experience
Previous work or volunteering experience
Referee
Referee Name
Referee Phone
Referee Role
Medical Information
List any medical conditions or limitations that may affect your work
Emergency Contact Information
1st Contact - Name
1st Contact - Relationship
1st Contact - Phone
2nd Contact - Name
2nd Contact - Relationship
2nd Contact - Phone
Training Requirements
Availability Indicate AM/PM availability:
PROOF OF IDENTITY
Please attach your Driver's License and/or Passport (for identification and/or for those driving on our behalf). If you can't attach your file, please have this copied at one of our shops or the office.
Motivation
What motivated you to volunteer for Hospice?
The information you supply will not be disclosed to any other party or organisation unless authorised. It will be held on a secure database, and you may request a copy of your information at any time.
Applicant Declaration
Signed Name
Date Signed
1.1 Name of the agency submitting the vetting request
1.2 Name of the vetting subject (the person being vetted)
1.3 Description of the role of the vetting subject (a brief description of the role, not the job title)
1.4 Which groups will the vetting subject be working with? (select all that apply)
1.5 Does the role involve caring for people in the home of the vetting subject?
1.6 Is the vetting subject:
1.7 Is the vetting subject a Children's Worker according to the Children's Act 2014, section 23(1)? If the vetting subject is not working with children/ young people (Q 1.4), answer ‘No’ then skip to question 1.11. If the vetting subject IS working with children (Q 1.4) AND is a volunteer (Q 1.6), answer ‘No’ then skip to question 1.9.
If not working with children/young people (Q1.4), tick 'No' then skip to 1.11. If working with children (Q1.4) AND a volunteer (Q1.6), tick 'No' then skip to 1.9.
1.9 Has the vetting subject previously been Police vetted by your agency? (If No, skip to 1.11)
1.11 What is the job title of the vetting subject?
1.12 Evidence of identity
To be completed by agency representative or identity referee. See the consent form guide for details on how to complete this section.
Agency Representative
Agency Rep - Full name
Agency Rep - Date
2.1 Information about your consent
The purpose of this form is to allow the New Zealand Police Vetting Service to confirm who you are using Police records, carry out a Police vet, and obtain your consent to share any relevant information with the agency that requested the vet.
What you are consenting to. You are agreeing that the Police Vetting Service can share relevant information they hold about you (if any) with the requesting agency. This information will be used to help the agency decide whether you are suitable for the role they are considering you for or that you are engaged in.The information that may be shared is outlined in section 2.2 of this form. For further details, you should refer to the Vetting Bill or visit the police vetting website .
You are also agreeing that the organisation that employs or engages you may provide information about your employment/engagement status to Police Vetting Service. See section 2.2(2) of this form.
Who collects your consent. The agency requesting the Police vet will collect your signed consent.Your rights under the Privacy Act 2020 include:
You may request a copy of the Police vet report provided to the agency by contacting the agency.
You can withdraw your consent to a Police vet at any time before the vetting process is complete by contacting the agency.
The agency may keep the Police vet only for as long as required for vetting purposes.
How long the information is valid for. The information in the Police vet is correct only at the time it is shared. It is up to the agency to decide how often they ask for updated vetting.
2.2 Information about you that may be shared
A Police vet will include the following information, if held by New Zealand Police. Please refer to the Police vetting website for more information regarding the Clean Slate Scheme , what may be released, and the vetting process.
Either:
A result indicating that no information is held or relevant to the purpose of the vetting request,
Or, one or both of:
The vetting subject's criminal record (if any), unless the Clean Slate Scheme applies.
A summary of other information that is readily retrievable, relevant to the purpose of the vetting request, and deemed accurate.
This may include pending charges, charges without conviction, youth court charges, infringement offences, demerit points, arrest warrants, involvement in family violence, overseas convictions, police investigations without charges, interactions with Police, and other information held by Police.
Information may also be released where it is subject to a suppression order or statutory prohibition, involves offences by individuals under 18, or relates to mental health or substance abuse issues.
If you had been vetted as a Children's Worker, and you continue to hold that role, the Police Vetting Service may release any newly obtained relevant information to the requesting agency at any time.
The Police Vetting Service will take reasonable steps to:
confirm that you are still employed or engaged as a Children's Worker – for this purpose, you consent to the requesting agency providing the Police Vetting Service with confirmation of your employment or engagement status in this role.
notify you before any information is disclosed.
Information provided in this consent form may be used to update New Zealand Police records.
2.3 Personal information
Family/last name (that you are most commonly known by)
Given/first and middle name(s)
Gender
Place of birth (Town/City/State)
Date of birth (dd/mm/yyyy) (must be 14 years of age or over)
Country of birth
NZ Driver Licence number
Name of parent or guardian (if vetting subject is 14 or 15 years old)
2.4 Other names Please include all other names you are or have been known by. Including, but not limited to: previous legal names (eg. maiden names, or due to divorce or adoption), aliases used, name changes by deed poll. Include ALL names - first, middle and last.
Family name
First name
Middle names
2.5 Permanent residntial address
Flat/number - and street name
Suburb
Postcode
Town/City
Authorisation of vetting subject. By signing this form:
I confirm that the information I have provided in this form is about me and is correct.
I have read and understood the information above.
I authorise New Zealand Police to disclose any personal information relevant to this application (as described above) to the agency making this request.
Full name
Date
If you are 14 or 15 years of age (as at the date of the application) please provide consent from a parent or guardian.
Parent/Guardian’s full name:
Date
Submit Application
