Application for Adult Membership	FORM

A1

Apr 2018

INSTRUCTIONS

The Applicant will complete all of this form, including the declarations and consents and forward to the Group Leader/Leader-In-Charge.

The Group Leader/Leader-In-Charge will sign and endorse the form with the details of the desired appointment and level of participation that the applicant may have before appointment, and send to their Supervising Commissioner, who will sign and forward it to the Region Office.

PLEASE WRITE CLEARLY IN BLOCK LETTERS

PERSONAL DETAILS
Title (e.g. Dr, Mr, Mrs)	Family Name
First Given Name	Other Given Names	M	F
Date of Birth	City/Town of Birth	Country of Birth	Nationality
Preferred First Name

(if different to First Given Name)	Maiden or Former Names (if any)
Marital Status
Partner's Name

(optional)	Religion / Denomination
Address	Town/Suburb	State
Postcode
Home Phone	( )	Mobile	( )	Work Phone	( )
Email 1	Email 2
Postal Address (if different)
Address	Town/Suburb	State
Postcode
Occupation	Skills/Hobbies
PREVIOUS SERVICE AS A MEMBER OF THE SCOUT MOVEMENT

INCLUDING INVOLVEMENT WITH SCOUTS AUSTRALIA NSW, INTERSTATE SERVICE AND/OR OVERSEAS SERVICE
Please attach a copy of your interstate or overseas service and training history	Previous Membership No. (if known)
State/Country	Appointment	Formation	Dates (From - To)
WORKING WITH CHILDREN CHECK

Please provide your current Working With Children Check Number.

Working With Children Check Number	W

W

C

Expiry Date
Note: The above WWCC status will be verified by Scouts online.

REGION USE ONLY

Name of Assigned Personal Leader Advisor
RECORD OF REFEREES CHECK	CONTACTED BY (Print Full Name)	DATE	APPLICATION SUPPORTED
Name 1:	Yes
No
Name 2:	Yes
No
COMPLETED REFERENCE CHECK DOCUMENTS MUST BE ATTACHED TO THIS A1
Reference Check Document for Name 1 Attached ( ( )
Reference Check Document for Name 2 Attached ( ( )

STATE OFFICE USE ONLY

Police Clearance Date
WWCC Verified Date

Membership No.
Scouts Australia NSW	Level 1, Quad 3,

102 Bennelong Parkway,

Sydney Olympic Park, NSW 2127	P O Box 125

Lidcombe, NSW 1825	Ph: 02 9735 9000

E-mail: info@nsw.scouts.com.au
APPLICANT:

PARTICIPATION CRITERIA

I nominate the person named in this application for appointment as an Adult Member in The Scout Association of Australia, New South Wales. The nomination is supported by two referees named below who have been contacted and the applicant is accepted as a person of suitable repute. Pending their appointment, I recommend that the applicant:

Please place an “X” in the appropriate box.

participate in youth

and adult meetings

OR

participate in adult meetings and adult training courses only

OR

not participate in any meeting until approval is received from State Office

Please note that until all required Training (e.g. Basic training for Adult Leaders) has been completed, the Adult Member is not to be left solely responsible for youth members.

NOMINATION FOR DESIRED APPOINTMENT

On receipt of a cleared Police Records Check and completion of required training, I recommend the person named in this application for appointment as:

Appointment
(e.g. Region Adviser, Cub Scout Leader, Region Commissioner Scouts)
Formation	Region
(e.g. 1st Haberfield Cub Scout Pack "Koala")

FORMATION ENDORSEMENT

Signature of Leader-in-Charge of Formation
Date
Print Name

REGION ENDORSEMENT

Signature of Supervising Commissioner /Leader
Date
Print Name	Appointment

Signature of Region Office Manager
Date
Print Name

Only those subscribing to the undermentioned Consents and Declaration shall be entitled to appointment as an Adult Member in The Scout Association of Australia, New South Wales Branch.

APPLICANT:

DECLARATION BY APPLICANT

I hereby apply for Adult Membership of the Scout Association of Australia, New South Wales Branch in the appointment specified.

i) Past Service

I have listed all my previous service as an Adult Member of the Scout Movement as required on page 1 of this form.

APPLICANT:

ii) Consent For Referees Check

I authorise the Scout Association to make any enquiries it sees fit as to my character, background, and suitability. Names and addresses of two responsible citizens, other than relatives or members of the Scout Association, to whom I am personally known, and of whom enquiries may be made are:

1. Name	Phone No.	( )
Address	Town/Suburb
2. Name	Phone No.	( )
Address	Town/Suburb

iii) Consent For Police Records Check

I authorise the Scout Association to undertake a check of Police records on a random and ongoing basis for purpose of disclosure of any conviction that may be recorded against me by a Court of Law. Also, for the furnishing of details concerning any matter that may be before such a Court but not yet finalised. The purpose for which such authorisation is given relates to my membership of The Scout Association of Australia, New South Wales Branch.

iv) Privacy Consent

I have received a copy of, or am aware of, the Scouts NSW Privacy Policy, which also contains its Photographic, Images and Digital Media policy, and I consent to the information collected on this form and through Scouting activities to be used in accordance with the rights and obligations set out in that policy. Also, I acknowledge that any third party, about whom information on this form has been provided by me, has been informed of the Association’s collection of their information and that they are aware of the Scouts NSW Privacy Policy. A copy of the policy is available from our website www.nsw.scouts.com.au .

v) Electronic Signatures

I accept that Scouts NSW may use electronic signatures as part of their processes. A copy of the policy is available from our website www.nsw.scouts.com.au .

vi) Undertaking

I understand and accept –

The Scout Promise and the Scout Law - as my personal undertaking, and as the foundation of Scouting;

That Scouting aims to prepare young people for good citizenship by training them in character, health and skills - with special emphasis on outdoor activities;

That Scouting gives primacy to its Duty of Care to Youth Members and will act initially to protect their interests over any competing interest;

The obligation to endeavour to equip myself by undertaking appropriate training, and in other ways, for the responsibilities which I am undertaking;

That my appointment and participation in Scouting may be suspended, withdrawn or cancelled at any time;

The Association’s Code of Behaviour (Ethics and Conduct) and agree to adhere to it at all times.

Scouts NSW policies and procedures, including:

CHECKLIST: Key policies discussed and links (or copies) supplied to new member	Leader in Charge

Initial when Complete
1	Introducing Scouting - Document supplied
2	Position Description - Web link and/or document supplied
3	Scouts NSW: LSG17 Personal Protection Policy & Procedures - Web link supplied
4	Scouts NSW Privacy Policy - Web link supplied
5	Scouts NSW Child Protection Policy - Web link supplied
6	Scouts Australia NSW Social Media Guidelines - Web link supplied
7	Sectional Books Issued - Web link and/or documents supplied
8	NSW Adult Training & Development Training Calendar - Web link supplied
9	Training Course Application (L1) - Web link supplied
10	In-Service Training Completion Report for Section (L10) - Web link supplied

EXTERNAL QUALIFICATIONS
Do you currently hold any of the following qualifications (Yes or No)? If YES, please attach a copy.
Copy Of The Certificate IV in Training and Assessment (TAE40110) certified by a JP
Copy Of The Provide First Aid Certificate

I understand that acceptance for appointment as an Adult Leader now or subsequently will place me under an obligation to complete Basic Training within one year and to complete Advanced Training within three years of that appointment.

I agree and undertake that if directed by the appropriate Commissioner at any time, to cease activities with the Association I will immediately comply with such direction without question, acknowledging that I have no entitlement to reasons being given.

I agree that if at any time I cease to hold a Working With Children Check clearance, my appointment will be immediately suspended.

APPLICANT:

I agree to return funds, property and records belonging to any part of the Scout Association, when I cease to perform the functions for which I was appointed, or when called upon to do so by my Commissioner, Region Association or by State Office.

I further agree to abide by the Policies, Rules and Regulations now in force, or which may be issued by the authority of The Scout Association of Australia, New South Wales.

I agree to the terms of the following Mutual Agreement.

vii) Mutual Agreement

The Mutual Agreement defines the relationship between the applicant and the Association. The respective commitments of the Applicant and the Association are set out below.

The Association’s commitment to the applicant:

a defined organisational framework in which to operate, characterised by equity and fairness with a
right to be heard

a personal development process that recognises existing skills and leads to enhanced personal and
functional competencies

consideration of individual needs in appointment

a variety of leadership roles in a team environment

the opportunity to contribute to the personal development of young people

opportunities for community service

appreciation and recognition of individual contribution

opportunities to voluntarily participate in international activities

advice and access to programs and materials to carry out the task

Public Liability Insurance for actions consistent with the policies of the Association

opportunities for friendship and fellowship

opportunities to participate in a wide range of activities.

The applicant’s commitment to the Association:

to live by the Scout Promise and Law and to accept the Code of Ethics and Code of Conduct for
Adults in Scouting

to work to achieve the Aim, Principles and Method of the Association

to adhere to the Policy and Rules of the Association

to represent and promote the Scout Movement to the community

to be a role model to youth members and to adults

to accept the responsibility of working with young people (including Duty of Care, treating with respect, etc.)

to accept the authority of the Association

to actively participate in the Personal Development process of the Association

to acknowledge that teamwork is a basic of Scouting, requiring active cooperation with others and respect for their views and values

Signature of Applicant X
Date
Print Name
Signature of Leader in Charge
Date
Print Name
Matters which may adversely affect my character or the reputation of Scouts

I have reviewed this document in detail, as well as the policies referred to in it, and am satisfied that I understand them. I accept the Code of Ethics, Code of Conduct and Expectation Agreement as outlined. In addition, I make the following declarations in support of my application:

Please place an “X” in the appropriate boxes.

APPLICANT:
Have you ever been found guilty of an offence of any sexual nature committed in Australia or another country?
Yes
No
Have you ever been charged, reported, or defended in a court of law any allegation of sexual abuse, assault or a sexual offence of any kind in Australia or in another country?
Yes
No
Have you ever been (or are you currently) subject to any restrictions regarding your contact with children in any employment, volunteer or personal capacity?
Yes
No
Have you ever been dismissed or resigned as a volunteer or employee (or reported by any authority) for improper conduct relating to children in any jurisdiction?
Yes
No
Have you been named as the defendant in an Intervention Order, Apprehended Violence Order or Domestic Violence Restraining Order, or equivalent, in any jurisdiction?
Yes
No

If you answered “yes” to any of the previous questions, please submit a detailed summary of the circumstances surrounding the situation with your application. This should include dates and, where applicable, the reasons for the decision, conditions of employment, offence type and date, the court in which the matter was heard, and the status of any proceedings.

Place this in a sealed envelope marked "confidential" and attach it to your completed Application for Adult Membership form addressed to "Child Protection & Issues Management Officer". Scouts Australia NSW reserves the unfettered right to accept or reject your application per its Child Protection Policy.

You commit to advise Scouts Australia NSW within 72 hours if you are ever approached by the authorities in relation to any allegation made against you of improper conduct relating to children, assault, or any sexual offence by you or if you are required to attend Court in respect of allegations that you have committed any other offence, whilst you are a member.

Matters which may affect my ability to fulfil the inherent requirements
of the position applied for with Scouts

Please place an “X” in the appropriate boxes.

Do you suffer from any physical, psychological or emotional condition which without adjustment may affect your ability to deliver the Scouting program in a way which is safe to yourself and to those whom you have a duty of care? (If you answered "yes", please prepare a short report, setting out details of any such condition, and the steps which can be reasonably taken which will allow you to comply).

Yes

No

Do you have any condition which may affect your concentration, or ability to direct and control children at any time of stress? (If you answered "yes", please provide details of any treatment plan which you have to deal with your condition).

Yes

No

APPLICANT:

If you do not wish to provide any additional information on this form, please place any additional information in a sealed envelope marked "confidential" and attach it to your completed Application for Adult Membership form addressed to "Child Protection & Issues Management Officer". Scouts Australia NSW reserves the unfettered right to accept or reject your application per its Child Protection Policy.

I agree to inform Scouts promptly if I become aware of any of the previous conditions or other conditions which may interfere with my ability to fulfil the inherent requirements of the position applied for or held by me within Scouts and I acknowledge that my application may be declined and/or that my membership appointment may be terminated if the relevant Commissioner determines in their discretion that such condition prevents me from fulfilling the inherent requirements of my duties.

Signature of Applicant X
Date

CODE OF ETHICS

Integrity We demonstrate Integrity by:

Acting with honesty, truthfulness and fostering appropriate healthy professional relationships

Recognising and fulfilling where possible, our obligations to our community

Taking responsibility for our own actions and developing integrity in others

Acting with impartiality, truthfulness and honesty.

Respect We demonstrate Respect by:

Showing consideration to others, recognising each individual’s uniqueness and diversity

Minimising our impact on the environment and seeking to be good caretakers for future generations

Committing to members well-being and on-going learning through the practice of positive influence, good judgement and empathy in practice.

Courage We demonstrate Courage by:

Providing challenging, developmental opportunities to empower young people

Being good role models in Scouting, demonstrating positive attitudes and willingness to live by the Scout Promise and Law

Being fair and reasonable

CODE OF CONDUCT

This Code of Conduct is a personal commitment. Its purpose is to protect all members of Scouting. It applies to all members over the age of 18, regardless of location and role, when engaging with young people and adults in any form. This includes face to face contact and using technology such as on-line formats. Parents and guardians who wish to actively participate in Scouting activities must also follow this Code.

“I will set an example that I would wish others to follow.

Therefore, I will:

Respect the dignity of myself and others.

Demonstrate a high degree of individual responsibility,

Recognise at all times that my words and actions are an example to other members of the Movement.

Act at all times in accordance with the Promise and Law, Code of Ethics and this Code of Conduct, thereby setting a suitable example for all.

Not use the Movement to promote my own beliefs, behaviours and practices where these are not compatible with Scouting Principles.

Adhere to the Scouts Australia Child Protection Policy and provide a safe environment for youth members participating in the Scout Program, their parents or guardians and visitors.

Report any conduct seen or heard that does not comply with this Code of Conduct to the appropriate Scouting person."

I have read, understood and will abide by the Code of Ethics and Code of Conduct.

Signature of Applicant X
Date
APPLICANT:

FORM A1 Apr 18 … Page 5 of 7

Wanda Whittaker (Scouts Australia NSW)

2018-04-11

Hewlett-Packard Company