Carer reference group application form

Carer Reference Group (CRG) Application Form

"*" indicates required fields

SECTION 1. PERSONAL DETAILS

Title*

Name*

Organisation (you work for or are a carer with)*

Home Address*

Street City State / Province / Region ZIP / Postal Code

Postal Address (if different)*

Postal Address

Street City State / Province / Region ZIP / Postal Code

Phone*

Mobile*

Email*

Do you identify as an Aboriginal or Torres Strait Islander?*

Are you from a culturally or linguistically diverse background?*

Details:

Please select your role*

SECTION 2. COMMUNITY INVOLVEMENT AND SKILLS

Briefly describe what you think are some important issues for carers in NSW.

Please outline the reasons why you would like to join a CRG.

Please describe the type of care you provide (e.g. short-term, emergency, part-time, long-term) and the skills, knowledge and experience you can bring to the CRG.

Please describe your role/position and outline the skills, knowledge and experience you could bring to the CRG.

SECTION 3. REFEREES

Please provide the name and contact details of two referees. At least one referee must be a caseworker/casework manager from your agency or manager (if you are an employee).

Referee 1:

Agency

Relationship to applicant

Phone

Referee 2:

Agency

Relationship to applicant

Phone

SECTION 4. STATEMENT/AGREEMENT

In expressing my interest in becoming a member of the Carer Reference Group

I understand that being part of this group will require members to attend and contribute positively to quarterly meetings, forums and other activities as required.

I understand that training sessions may be provided to assist the development and work of the group and note that I am willing to participate in these or similar activities.

Signed

Date

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