WORKING AT PALS Student Placement Application Form Personal DetailsName* First Middle Last Maiden/Previous Names Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Date of Birth* DD slash MM slash YYYY Email* Gender* Male Female Other Emergancy Contacts(Please supply details for 2 emergency contacts. These should be responsible adults who, for example, can assist you to travel if necessary)Name 1* First Last Relationship 1* Address 1* Street Address Address Line 2 City State Post Code Phone 1*Name 2* First Last Relationship 2* Address 2* Street Address Address Line 2 City State Post Code Phone 2*Student Placement RoleName of course you are currently studying Hours to be completed* AvailabilityDayMorning 9am - 1pmAfternoon 1pm - 5pmEvening 5pm - 7pmAll Day Are you interested in volunteering for one-off events? Yes No Do you have your own means of transport?* Yes No Do you have the following? Select All NDIS-worker-screening-check First Aid / CPR Driver's Licence RefereesPlease nominate two referees e.g. ministers, employers, adult educators (excluding family members) It is important that you seek permission from your proposed referees before we contact them. Please note that referees will be contacted by PALS IncName 1* First Last Phone 1*Name 2* First Last Phone 2CAPTCHA
