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Application for Student Placement

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Application for Student Placement

Pre-application Questions
Have you had experience, either in your personal or work life, with people living with dementia?*
- Yes
- No
Contact
Title:*
First Name:*
Surname:*
Date of Birth*
MM slash DD slash YYYY
Postal Address:*
Suburb:*
State:*
Home Phone:
Mobile Phone:
Email*
Best time to contact you:
Placement Details
Have you had exposure to people living with dementia? Explain:
Where are you undertaking studies?
What are you studying?
When are you available?*
How long is the placement for? (please advise duration and/or hours)
Medical and Health
Do you have (or have you had) a medical or health problem which may affect your volunteer work, or that we should otherwise know about in the event of an emergency?*
- Yes
- No
If 'Yes', please give details*
If 'Yes', please provide year of claim and injury details.*
If 'Yes', please give details*
Some of our volunteer roles include driving one of our small mini buses, if you have applied for one of these role please can you include your drivers license details below:
Driver's License Number
License Classes Held
Emergency Contact
Person to be contacted in Emergency*
Relationship
Contact Number
Address
Declaration
I certify that the information provided above is correct*
- Yes
Name:*
Date:*
Police Clearance
If your placement is a client facing role, you are required to hold either a national or a volunteers police clearance. Do you currently have either of these that is less than six months old? If you do not hold either do you agree to complete a volunteer police clearance at your own cost?*
- Yes
- No
I consent to Alzheimer’s WA keeping a copy of my volunteering police clearance on file:
If successful, Alzheimer's WA will require personal accident insurance from your educational institution (University / TAFE)*
- Accept
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Name
This field is for validation purposes and should be left unchanged.

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