Volunteer Registration Form

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Please complete this form to confirm your volunteering interest with EMR Taranaki

Email *

First Name *

Surname *

Date of Birth

YYYY

Cellphone number *

Dietary Requirements *

Omnivore

Vegetarian

Vegan

Gluten free

Other:

Medical Conditions?

None

Asthma

Allergies

Disabilities

Seizures of any type

Epilespy

Heart condition

Other:

Please elaborate on medical conditions

Are you currently on any medication?

Yes

Clear selection

If yes, please state what medication/s you are on:

Please ensure you bring your own medication for any medical conditions.

Are you allergic to any of the following:

Insect bites

Bee stings

Jelly fish

Seawater

If yes to insect bites/ stings, what reaction do you have:

What treatment is required?

Level of swim fitness

Very fit (can swim >200m)

Moderately fit (can swim 200m)

Not very fit (Cant swim 200m)

Clear selection

Emergency contact details

Please use someone that is local

Name *

Relationship *

Contact phone number *

Have you volunteered with EMR before? *

Yes

If so, in what capacity?

What relevant work experience/qualifications do you have? *

Skills/Experience - Select those which apply *

Organisation management

Report writing - funding applications

Developing educational resources

Advertising

Press writing

Photography

Snorkel/dive guiding

Teaching marine education in the field

Other:

Required

Do you have any of the following qualifications?

Full drivers license

Dive/snorkel qualifications

Boatmasters

Day Skippers

Teaching qualifications

First aid

Marine/freshwater biology degree

Other:

Do you have any criminal convictions? *

Yes

If yes, please elaborate

Drug and alcohol policy

By signing this form you agree to abide by MTSCT’s drug and alcohol policy which includes not being under the influence of drugs or alcohol when involved in MTSCT safety sensitive activities and public events.

Medical conditions

On the day of event participation - Please advise the supervisor if there has been any change to your medical situation.

Criminal convictions/ police vetting policy

MTSCT is committed to provide a safe environment for everyone we work and associate with. Furthermore, under the Children's Act 2014, we have a special duty to protect and care for children under the age of 18. MTSCT will conduct police vets from time to time to ensure we comply with our obligations under the Children's Act 2014 and to check that information given to us by volunteers is correct. By clicking the box below you declare that you have never made a child feel unsafe in your presence. By clicking the box below you confirm that you do not have any criminal convictions relating to sexual offence, offence relating to children or act of violence. By clicking the box below you further consent to a police vet if requested by MTSCT. This information remains strictly confidential. Please note that you are obliged to disclose any new or pending criminal charges that relate to the above to MTSCT."

Do you agree to the above policies?

Yes, I agree to these policies

Clear selection

Risk Disclosure - Snorkelling (if applicable)

I hereby acknowledge the risks associated with snorkelling. I understand that the EMR programme will identify any foreseeable risks or hazards and implement correct management procedures to eliminate or minimise those hazards.

Volunteer Responsibility

Ø Take reasonable care of your own health and safety,
Ø Take reasonable care that what you do or don’t do doesn’t adversely affect the health and safety of others,
Ø Cooperate with any reasonable policies or procedures the business or undertaking has in place on how to work in a safe and healthy way, and
Ø Comply with any reasonable instruction given by the business or undertaking so that they can comply with HSWA and the regulations.

Volunteer Privacy

We collect personal information from you in order to ensure your own Health and Safety and the safety of others when participating in an EMR activity. If you choose to withhold information from EMR you may not be able to participate in any EMR activity (i.e. medical information). We will share this information with MTSCT staff where deemed necessary for H&S purposes.

By signing this form you agree to the MTSCT privacy statement which is found on our website.

Complaints

Refer to our complaints policy on our website. Health and safety feedback and/or comments can also be submitted via our programme websites www.emr.org.nz & www.whitebaitconnection.co.nz

Liability Statement

I accept that any medical costs associated with accidents are to be classified as nonwork related and will be paid for by the ACC or other means and under no circumstances by the (Mountains to Sea Conservation Trust). (The Mountains to Sea Conservation Trust) does not accept any responsibility whatsoever for any personal accident or loss/damage to personal items or equipment for volunteers whilst they are engaged in the project.

Volunteer Declaration

In entering your name and date below you understand the risks and liability outlined above.

Your full name *

Date *

YYYY

A copy of your responses will be emailed to the address you provided.

Submit

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