Online Form - EVRC - Agency Membership Form

Agency Name*

Agency ABN*

Email*

Phone*

Physical Address

Street Address:*

City:*

State:*

Post Code:*

Country:*

Mailing Address - Same as street address?*

YesNo

Description of Agency*

Incorporated?*

YesNoUnsure

Volunteering Roles Offered*

Number of Current Volunteers*

Number of Current Paid Staff*

Agency is a Centrelink Approved Organisation?*

YesNo

Would you like information and/or assistance with any of the following? Please tick.*

Volunteer Recruitment
The National Standards for Volunteer Involvement
Policies & Procedures
Volunteer Recognition
Writing Volunteer Position Descriptions
Risk Management
Inclusion & Diversity
Emergency / Event Volunteering
Exiting Volunteers
None
Other: Please specify below

Other (from question above):

Service Focus*

Animal Welfare
Disability Services
Education & Training
Family Services
Human Rights
Migrant Services
Seniors & Aged Care
Young People
Arts & Culture
Disaster Relief
Emergency Response
Health
Indigenous Australians
Museums & Heritage
Sport
Community Services
Drug & Alcohol Services
Environment / Conservation
Homeless
Mentoring & Advocacy
Recreation
Veteran Services
Other: Please specify below

Other (from question above):

Public Liability Insurance: Policy Number*

Public Liability Insurance: Policy Expiry Date:*

Public Liability: Insurance Company*

Have you emailed a copy of your Public Liability Insurance Policy to volunteer@esperance.wa.gov.au ?*

YesNo

Volunteer Personal Accident Policy Number:*

Volunteer Personal Accident Policy Expiry Date:*

Volunteer Personal Accident Policy: Insurance Company*

Have you emailed a copy of your Volunteer Personal Accident policy to volunteer@esperance.wa.gov.au ?*

YesNo

Volunteer Coordinator Name*

Volunteer Coordinator Job Title*

Contact Phone*

Contact Email*

Preferred Contact Method

Phone
Email

Subscribe to Esperance Volunteer Resource Centre Email List*

YesNo

Agency Representative Name*

Agency Representative Job Title*

Signature*

Date*

Online Form - EVRC - Agency Membership Form

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