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Name: gg g gg Previous Name/s (e.g. maiden names, legal name changes, aliases): g Date Of Birth: g Country Of Birth: g Do you identify as either Aboriginal or Torres Strait Islander?: If yes, please tick appropriate:: Are you an Australian Citizen?: Do you speak other languague, other than English?: Religion: Current Home Address: Date (MM/YYYY – Current): What type of residence do you live in?: Previous home addresses (all addresses Applicant has lived in the past 10 years – required for background checks): Previous Home Addresses: Contact Phone Number - Home: Contact Phone Number - Work: Contact Phone Number - Mobile: Email Address: karenr@theequanimityproject.org Currently Employed: If you are currently employed, tick appropriate: If you have a degree, diploma, or certification, please specify: Do you have any specialist skills such as caring for young children through your employment, children with disabilities or have done volunteer work previously? Please provide details: Marital Status: Partnered Do you have any children?: Yes If yes, how old?: Are they living in your home?: Do you have any medical/ health conditions at the time of Application?: If yes, please specify: I/We provide the following names and addresses of two responsible people to act as referee to my application. Please tick which is appropriate. These individuals: are in current contact with me have known me for at least two years have observed me interacting with people and children/pets on a regular basis Referee 1 - Name: Referee 1 - Home Address: Referee 1 - Email Address: Referee 1 - Phone Number: Single Line Text: Referee 1 - Relationship to Applicant: Referee 2 - Home Address: Referee 2 - Email Address: Referee 2 - Phone Number: Referee 2 - Relationship to Applicant: It is important that we understand your preferences for providing a Host Client nurturing care and support. Please tick which is appropriate. As a Nurture Carer I am interested in supporting: A woman on her own A woman with a pet (Indicate preference: cat / dog / either) Length of time. Tick which is appropriate: A. Have you previously been employed by, or contracted to FACS, Community Services, DCJ, ADHC or Housing NSW?: Yes If yes, please provide dates of employment and division: B. Have you or any member of your family been involved with child protection authorities (e.g. FACS, DcCS, DCJ) in NSW or any other State or Territory?: Yes If yes, please provide details: the name(s) of the person(s) who has been involved with child protection authorities and the State or territory where this occurred.: C. What previous experience do you have in caring for children, if any (other than parenting)?: D. Would you consider caring for an Aboriginal women/with child/children?: E. Do you have a current driver’s license:: F. Do you have a motor vehicle that is comprehensively insured?: If you answered yes, please state licence plate number:: I am applying to be a Nurture Carer for The Equanimity Project (Australia) Limited (TEP). Please mark each box to indicate you have read and agreed or provided any attachments as requested.: I agree to take part in the process of assessment for suitability as a Nurture Carer, and I understand it will include further discussions before I have a placement of a Host Client. I agree and understand that as part of this approval process I need to complete a DV Alert Course (minimum 1-day course) run and operated by Lifeline. Confirmation of my attendance will be required to be provided before signing my agreement with TEP. I understand that I can withdraw this application at any stage. This will not prevent my re-application, but my reason(s) for withdrawal will be documented and discussed with me if I do re-apply. I understand that any friends or family who do visit my property on a regular basis may require an Identity/Children/Criminal Check but there will be discussions with me prior to this occurring. I understand that The Equanimity Project (Australia) will ask my permission to contact any other people or agencies who are able to provide relevant information regarding my suitability to provide Care. I understand that a security check and walk through will be conducted at my home to assure the safety of myself and my Host Client. I understand that I may need to have a Medical Certificate issued from my general practitioner to confirm that I have no medical issues that may affect supporting a Home Client. I have provided copies of three forms of identification either certified by a JP or sighted by The Equanimity Project (Australia) staff. I give consent for the information collected in the assessment process to be stored with The Equanimity Project (Australia) and used for the purpose of determining my suitability as a Nurture Carer. I understand that the information collected in the assessment process will be treated confidentially unless disclosure is required under law or agency accreditation requirements, including providing information for the Nurture Carer Register, to other organisations for the purpose of background checks or to courts under subpoena. I state that the information contained in this Application, including all attachments, is correct to the best of my knowledge. Signature: Applicant Name: Date: Please confirm the attachments required are completed: Working with Children’s Check Clearance Letter National Police Informed Consent Form (Criminal Record Check Form) Compiled by: Name: Date: Authorised by: Name: Date:
Name: dkoiujola fffff Previous Name/s (e.g. maiden names, legal name changes, aliases): Date Of Birth: Country Of Birth: Do you identify as either Aboriginal or Torres Strait Islander?: If yes, please tick appropriate:: Are you an Australian Citizen?: Do you speak other languague, other than English?: Religion: Current Home Address: Date (MM/YYYY – Current): What type of residence do you live in?: Previous home addresses (all addresses Applicant has lived in the past 10 years – required for background checks): Previous Home Addresses: Contact Phone Number - Home: Contact Phone Number - Work: Contact Phone Number - Mobile: Email Address: karenr@theequanimityproject.org Currently Employed: If you are currently employed, tick appropriate: If you have a degree, diploma, or certification, please specify: Do you have any specialist skills such as caring for young children through your employment, children with disabilities or have done volunteer work previously? Please provide details: Marital Status: Do you have any children?: If yes, how old?: Are they living in your home?: Do you have any medical/ health conditions at the time of Application?: If yes, please specify: I/We provide the following names and addresses of two responsible people to act as referee to my application. Please tick which is appropriate. These individuals: Referee 1 - Name: Referee 1 - Home Address: Referee 1 - Email Address: Referee 1 - Phone Number: Single Line Text: Referee 1 - Relationship to Applicant: Referee 2 - Home Address: Referee 2 - Email Address: Referee 2 - Phone Number: Referee 2 - Relationship to Applicant: It is important that we understand your preferences for providing a Host Client nurturing care and support. Please tick which is appropriate. As a Nurture Carer I am interested in supporting: A woman on her own A woman with a pet (Indicate preference: cat / dog / either) Length of time. Tick which is appropriate: A. Have you previously been employed by, or contracted to FACS, Community Services, DCJ, ADHC or Housing NSW?: No If yes, please provide dates of employment and division: B. Have you or any member of your family been involved with child protection authorities (e.g. FACS, DcCS, DCJ) in NSW or any other State or Territory?: No If yes, please provide details: the name(s) of the person(s) who has been involved with child protection authorities and the State or territory where this occurred.: C. What previous experience do you have in caring for children, if any (other than parenting)?: D. Would you consider caring for an Aboriginal women/with child/children?: Yes E. Do you have a current driver’s license:: Yes F. Do you have a motor vehicle that is comprehensively insured?: If you answered yes, please state licence plate number:: I am applying to be a Nurture Carer for The Equanimity Project (Australia) Limited (TEP). Please mark each box to indicate you have read and agreed or provided any attachments as requested.: I agree to take part in the process of assessment for suitability as a Nurture Carer, and I understand it will include further discussions before I have a placement of a Host Client. I agree and understand that as part of this approval process I need to complete a DV Alert Course (minimum 1-day course) run and operated by Lifeline. Confirmation of my attendance will be required to be provided before signing my agreement with TEP. I understand that I can withdraw this application at any stage. This will not prevent my re-application, but my reason(s) for withdrawal will be documented and discussed with me if I do re-apply. I understand that any friends or family who do visit my property on a regular basis may require an Identity/Children/Criminal Check but there will be discussions with me prior to this occurring. I understand that a nationwide criminal record check will be conducted and possibly an international criminal check if I was born overseas. I understand that a criminal record does not automatically debar me from being a Nurture Carer, but the implication of any convictions on my suitability to be a Nurture Carer will be discussed with me and will be taken into account in the assessment process. I understand that The Equanimity Project (Australia) will ask my permission to contact any other people or agencies who are able to provide relevant information regarding my suitability to provide Care. I understand that a security check and walk through will be conducted at my home to assure the safety of myself and my Host Client. I understand that I may need to have a Medical Certificate issued from my general practitioner to confirm that I have no medical issues that may affect supporting a Home Client. I have provided copies of three forms of identification either certified by a JP or sighted by The Equanimity Project (Australia) staff. I give consent for the information collected in the assessment process to be stored with The Equanimity Project (Australia) and used for the purpose of determining my suitability as a Nurture Carer. I understand that the information collected in the assessment process will be treated confidentially unless disclosure is required under law or agency accreditation requirements, including providing information for the Nurture Carer Register, to other organisations for the purpose of background checks or to courts under subpoena. I state that the information contained in this Application, including all attachments, is correct to the best of my knowledge. Signature: Applicant Name: Date: Please confirm the attachments required are completed: Compiled by: Name: Date: Authorised by: Name: Date:
Name: mfmfmfmd d dddd Previous Name/s (e.g. maiden names, legal name changes, aliases): ddddd Date Of Birth: 29/09/1955 Country Of Birth: australia Do you identify as either Aboriginal or Torres Strait Islander?: No If yes, please tick appropriate:: Are you an Australian Citizen?: Yes Do you speak other languague, other than English?: yrd Religion: jj Current Home Address: f;;lkdk;ld Date (MM/YYYY – Current): ffff What type of residence do you live in?: Previous home addresses (all addresses Applicant has lived in the past 10 years – required for background checks): Previous Home Addresses: Contact Phone Number - Home: Contact Phone Number - Work: Contact Phone Number - Mobile: Email Address: krlevin13@bigpond.com Currently Employed: No If you are currently employed, tick appropriate: If you have a degree, diploma, or certification, please specify: Do you have any specialist skills such as caring for young children through your employment, children with disabilities or have done volunteer work previously? Please provide details: Marital Status: Divorced Do you have any children?: No If yes, how old?: Are they living in your home?: Do you have any medical/ health conditions at the time of Application?: If yes, please specify: I/We provide the following names and addresses of two responsible people to act as referee to my application. Please tick which is appropriate. These individuals: Referee 1 - Name: Referee 1 - Home Address: Referee 1 - Email Address: Referee 1 - Phone Number: Single Line Text: Referee 1 - Relationship to Applicant: Referee 2 - Home Address: Referee 2 - Email Address: Referee 2 - Phone Number: Referee 2 - Relationship to Applicant: It is important that we understand your preferences for providing a Host Client nurturing care and support. Please tick which is appropriate. As a Nurture Carer I am interested in supporting: Length of time. Tick which is appropriate: A. Have you previously been employed by, or contracted to FACS, Community Services, DCJ, ADHC or Housing NSW?: If yes, please provide dates of employment and division: B. Have you or any member of your family been involved with child protection authorities (e.g. FACS, DcCS, DCJ) in NSW or any other State or Territory?: If yes, please provide details: the name(s) of the person(s) who has been involved with child protection authorities and the State or territory where this occurred.: C. What previous experience do you have in caring for children, if any (other than parenting)?: D. Would you consider caring for an Aboriginal women/with child/children?: E. Do you have a current driver’s license:: F. Do you have a motor vehicle that is comprehensively insured?: If you answered yes, please state licence plate number:: I am applying to be a Nurture Carer for The Equanimity Project (Australia) Limited (TEP). Please mark each box to indicate you have read and agreed or provided any attachments as requested.: I agree to take part in the process of assessment for suitability as a Nurture Carer, and I understand it will include further discussions before I have a placement of a Host Client. I agree and understand that as part of this approval process I need to complete a DV Alert Course (minimum 1-day course) run and operated by Lifeline. Confirmation of my attendance will be required to be provided before signing my agreement with TEP. I understand that I can withdraw this application at any stage. This will not prevent my re-application, but my reason(s) for withdrawal will be documented and discussed with me if I do re-apply. I understand that any friends or family who do visit my property on a regular basis may require an Identity/Children/Criminal Check but there will be discussions with me prior to this occurring. I understand that a nationwide criminal record check will be conducted and possibly an international criminal check if I was born overseas. I understand that a criminal record does not automatically debar me from being a Nurture Carer, but the implication of any convictions on my suitability to be a Nurture Carer will be discussed with me and will be taken into account in the assessment process. I understand that The Equanimity Project (Australia) will ask my permission to contact any other people or agencies who are able to provide relevant information regarding my suitability to provide Care. I understand that a security check and walk through will be conducted at my home to assure the safety of myself and my Host Client. I understand that I may need to have a Medical Certificate issued from my general practitioner to confirm that I have no medical issues that may affect supporting a Home Client. I have provided copies of three forms of identification either certified by a JP or sighted by The Equanimity Project (Australia) staff. I give consent for the information collected in the assessment process to be stored with The Equanimity Project (Australia) and used for the purpose of determining my suitability as a Nurture Carer. I understand that the information collected in the assessment process will be treated confidentially unless disclosure is required under law or agency accreditation requirements, including providing information for the Nurture Carer Register, to other organisations for the purpose of background checks or to courts under subpoena. I state that the information contained in this Application, including all attachments, is correct to the best of my knowledge. Signature: Applicant Name: Date: Please confirm the attachments required are completed: Compiled by: Name: Date: Authorised by: Name: Date:
Name: Second Test Test Previous Name/s (e.g. maiden names, legal name changes, aliases): Date Of Birth: Country Of Birth: Do you identify as either Aboriginal or Torres Strait Islander?: If yes, please tick appropriate:: Are you an Australian Citizen?: Do you speak other languague, other than English?: Religion: Current Home Address: Date (MM/YYYY – Current): What type of residence do you live in?: Previous home addresses (all addresses Applicant has lived in the past 10 years – required for background checks): Previous Home Addresses: Contact Phone Number - Home: Contact Phone Number - Work: Contact Phone Number - Mobile: Email Address: aaa@ksjs.com Currently Employed: Yes If you are currently employed, tick appropriate: If you have a degree, diploma, or certification, please specify: dd Do you have any specialist skills such as caring for young children through your employment, children with disabilities or have done volunteer work previously? Please provide details: ddd Marital Status: Single Do you have any children?: No If yes, how old?: Are they living in your home?: Do you have any medical/ health conditions at the time of Application?: Yes If yes, please specify: ddd I/We provide the following names and addresses of two responsible people to act as referee to my application. Please tick which is appropriate. These individuals: are in current contact with me have known me for at least two years Referee 1 - Name: d Referee 1 - Home Address: d Referee 1 - Email Address: Referee 1 - Phone Number: Single Line Text: Referee 1 - Relationship to Applicant: Referee 2 - Home Address: Referee 2 - Email Address: Referee 2 - Phone Number: Referee 2 - Relationship to Applicant: It is important that we understand your preferences for providing a Host Client nurturing care and support. Please tick which is appropriate. As a Nurture Carer I am interested in supporting: A woman on her own A woman with two children Length of time. Tick which is appropriate: Short term (emergency only) A. Have you previously been employed by, or contracted to FACS, Community Services, DCJ, ADHC or Housing NSW?: No If yes, please provide dates of employment and division: B. Have you or any member of your family been involved with child protection authorities (e.g. FACS, DcCS, DCJ) in NSW or any other State or Territory?: No If yes, please provide details: the name(s) of the person(s) who has been involved with child protection authorities and the State or territory where this occurred.: C. What previous experience do you have in caring for children, if any (other than parenting)?: dd D. Would you consider caring for an Aboriginal women/with child/children?: No E. Do you have a current driver’s license:: No F. Do you have a motor vehicle that is comprehensively insured?: No If you answered yes, please state licence plate number:: I am applying to be a Nurture Carer for The Equanimity Project (Australia) Limited (TEP). Please mark each box to indicate you have read and agreed or provided any attachments as requested.: I agree to take part in the process of assessment for suitability as a Nurture Carer, and I understand it will include further discussions before I have a placement of a Host Client. I agree and understand that as part of this approval process I need to complete a DV Alert Course (minimum 1-day course) run and operated by Lifeline. Confirmation of my attendance will be required to be provided before signing my agreement with TEP. I understand that I can withdraw this application at any stage. This will not prevent my re-application, but my reason(s) for withdrawal will be documented and discussed with me if I do re-apply. I understand that any friends or family who do visit my property on a regular basis may require an Identity/Children/Criminal Check but there will be discussions with me prior to this occurring. I understand that a nationwide criminal record check will be conducted and possibly an international criminal check if I was born overseas. I understand that a criminal record does not automatically debar me from being a Nurture Carer, but the implication of any convictions on my suitability to be a Nurture Carer will be discussed with me and will be taken into account in the assessment process. I understand that The Equanimity Project (Australia) will ask my permission to contact any other people or agencies who are able to provide relevant information regarding my suitability to provide Care. I understand that a security check and walk through will be conducted at my home to assure the safety of myself and my Host Client. I understand that I may need to have a Medical Certificate issued from my general practitioner to confirm that I have no medical issues that may affect supporting a Home Client. I have provided copies of three forms of identification either certified by a JP or sighted by The Equanimity Project (Australia) staff. I give consent for the information collected in the assessment process to be stored with The Equanimity Project (Australia) and used for the purpose of determining my suitability as a Nurture Carer. I understand that the information collected in the assessment process will be treated confidentially unless disclosure is required under law or agency accreditation requirements, including providing information for the Nurture Carer Register, to other organisations for the purpose of background checks or to courts under subpoena. I state that the information contained in this Application, including all attachments, is correct to the best of my knowledge. Signature: Applicant Name: ss Date: 10/01/2021 Please confirm the attachments required are completed: National Police Informed Consent Form (Criminal Record Check Form) Signed Code of Conduct Compiled by: s Name: s Date: 09/29/2021 Authorised by: s Name: s Date: 09/30/2021
Name: TEst Test Name Previous Name/s (e.g. maiden names, legal name changes, aliases): Date Of Birth: 01/12/1990 Country Of Birth: Australia Do you identify as either Aboriginal or Torres Strait Islander?: No If yes, please tick appropriate:: Are you an Australian Citizen?: Yes Do you speak other languague, other than English?: Other Religion: Other Current Home Address: 8/70 Flinders St Date (MM/YYYY – Current): 01/01/2021 -current What type of residence do you live in?: Unit Previous home addresses (all addresses Applicant has lived in the past 10 years – required for background checks): 8/70 Flinders St Previous Home Addresses: 8/70 Flinders St Contact Phone Number - Home: +61424423820 Contact Phone Number - Work: Contact Phone Number - Mobile: Email Address: 1223@gmail.com Currently Employed: Yes If you are currently employed, tick appropriate: Casual If you have a degree, diploma, or certification, please specify: Do you have any specialist skills such as caring for young children through your employment, children with disabilities or have done volunteer work previously? Please provide details: Marital Status: Partnered Do you have any children?: No If yes, how old?: Are they living in your home?: Do you have any medical/ health conditions at the time of Application?: No If yes, please specify: I/We provide the following names and addresses of two responsible people to act as referee to my application. Please tick which is appropriate. These individuals: are not related to each other Referee 1 - Name: d Referee 1 - Home Address: d Referee 1 - Email Address: d Referee 1 - Phone Number: d Single Line Text: d Referee 1 - Relationship to Applicant: d Referee 2 - Home Address: d Referee 2 - Email Address: d Referee 2 - Phone Number: d Referee 2 - Relationship to Applicant: d It is important that we understand your preferences for providing a Host Client nurturing care and support. Please tick which is appropriate. As a Nurture Carer I am interested in supporting: A woman with a pet (Indicate preference: cat / dog / either) Length of time. Tick which is appropriate: Short term (emergency only) A. Have you previously been employed by, or contracted to FACS, Community Services, DCJ, ADHC or Housing NSW?: No If yes, please provide dates of employment and division: B. Have you or any member of your family been involved with child protection authorities (e.g. FACS, DcCS, DCJ) in NSW or any other State or Territory?: No If yes, please provide details: the name(s) of the person(s) who has been involved with child protection authorities and the State or territory where this occurred.: C. What previous experience do you have in caring for children, if any (other than parenting)?: d D. Would you consider caring for an Aboriginal women/with child/children?: No E. Do you have a current driver’s license:: No F. Do you have a motor vehicle that is comprehensively insured?: No If you answered yes, please state licence plate number:: I am applying to be a Nurture Carer for The Equanimity Project (Australia) Limited (TEP). Please mark each box to indicate you have read and agreed or provided any attachments as requested.: I agree to take part in the process of assessment for suitability as a Nurture Carer, and I understand it will include further discussions before I have a placement of a Host Client. I agree and understand that as part of this approval process I need to complete a DV Alert Course (minimum 1-day course) run and operated by Lifeline. Confirmation of my attendance will be required to be provided before signing my agreement with TEP. I understand that I can withdraw this application at any stage. This will not prevent my re-application, but my reason(s) for withdrawal will be documented and discussed with me if I do re-apply. I understand that any friends or family who do visit my property on a regular basis may require an Identity/Children/Criminal Check but there will be discussions with me prior to this occurring. I understand that a nationwide criminal record check will be conducted and possibly an international criminal check if I was born overseas. I understand that a criminal record does not automatically debar me from being a Nurture Carer, but the implication of any convictions on my suitability to be a Nurture Carer will be discussed with me and will be taken into account in the assessment process. I understand that The Equanimity Project (Australia) will ask my permission to contact any other people or agencies who are able to provide relevant information regarding my suitability to provide Care. I understand that a security check and walk through will be conducted at my home to assure the safety of myself and my Host Client. I understand that I may need to have a Medical Certificate issued from my general practitioner to confirm that I have no medical issues that may affect supporting a Home Client. I have provided copies of three forms of identification either certified by a JP or sighted by The Equanimity Project (Australia) staff. I give consent for the information collected in the assessment process to be stored with The Equanimity Project (Australia) and used for the purpose of determining my suitability as a Nurture Carer. I understand that the information collected in the assessment process will be treated confidentially unless disclosure is required under law or agency accreditation requirements, including providing information for the Nurture Carer Register, to other organisations for the purpose of background checks or to courts under subpoena. I state that the information contained in this Application, including all attachments, is correct to the best of my knowledge. Signature: Applicant Name: d Date: 09/16/2021 Please confirm the attachments required are completed: Working with Children’s Check Clearance Letter National Police Informed Consent Form (Criminal Record Check Form) Three Forms of Identification – Certified ID or ID Originals sighted by TEP staff. Signed Code of Conduct Signed Rights and Responsibilities Agreement Compiled by: d Name: d Date: 09/28/2021 Authorised by: d Name: d Date: 09/21/2021