Samford Support Network | Member Application Form

Welcome to the Samford Support Network
Membership Application System
Last updated: 24 March 2022 11:37 (NewMDB, Public)

Instructions
Thank you for your interest in being a part of the Samford Support Network. The Samford Support Network (SSN) will use this form to collect information about a person wishing to become a member of the Samford Support Network.

The membership application process follows 4 simple steps:

Step 1	Submit your basic contact details using the online Membership Application Form. Our Membership Coordinator will then contact you for a brief introduction and explain about the SSN and the different areas that you can become involved.
Step 2	When requested by SSN, complete the remainder of the Application Form online.
Step 3	SSN will conduct Criminal History Check and obtain your signatures on the Volunteer Code of Conduct and any other documents necessary.
Step 4	SSN will complete your induction relevant to your interests.

To be a Member you must:

Be at least 18 years of age and be fit enough to undertake the duties for which you are volunteering.
Reside in the Samford Village, Samford Valley, Wights Mountain, Camp Mountain, Highvale, Closeburn, Cedar Creek, Yugar or Draper.
Be willing to undergo National Criminal History check.
Be willing to be an unpaid volunteer.
Have a current open driver’s licence, a roadworthy car and comprehensive insurance.
Have a personal email address and Internet access.
Be willing to sign and adhere to the SSN Volunteer Code of Conduct.

Having a medical condition or illness does not necessarily preclude you from undertaking a particular role, but rather allows the SSN to support you in undertaking your role safely and appropriately.

Your application must be processed by SSN before you are considered a member. Please be aware that you are not covered by any of the protections offered to SSN volunteers, such as insurance, until you have received written confirmation of your membership from the SSN Management Committee.

Privacy Notice: Your personal information is protected by law, including the Privacy Act 1988, and is collected by the Samford Support Network Inc for the administration of your membership of the SSN, payments and services. Your information may be used by the SSN Management Committee and may be seen by advisors to the SSN (for example, for legal, accounting, audit purposes), our partners, or where you have agreed, or where it is required or authorised by law to be disclosed.

Lets get started:
You can start a New Application for Membership of the SSN by clicking Step 1 here.

After you have completed Step 1, you will be provided with your unique VID number from Step 1 by the Membership Coordinator and can then complete the remainder of your application details by following Step 2 here.

If you have any questions or need help with completing this form, please email SSN on SSN@samfordsupportnetwork.com or call the SSN phone number 0470 214 916.

SSN Member Application Form

Step 1: Basic contact details

If you require more information or have any questions, please contact one of the SSN Management Committee at SSN@samfordsupportnetwork.com or by calling the SSN phone number 0470 214 916.

This is STEP 1 of your application to be a member of the SSN. Please provide as many of the details as you can below and press the Green "Submit Form" button.

A confirmation email will be sent to you, and our Membership Coordinator will contact you within 7 days.

Step 2: Complete the remainder of the Application

This is Step 2 of the SSN Member Application Process.

By now you should have spoken with the SSN Membership Coordinator, given your unique VID number and advised to proceed to Step 2.

Please complete as much information in the additional fields below and press the Submit Form button.

Member VID

Member Status

Given Name

Family name

Preferred name

Full Name (given)

Full name (preferred)

Address Line 1

Address Line 2

Suburb

(You must reside in one of these Suburbs.)

Postcode

Date of Birth

Gender

eMail

Home Phone

Work number

Mobile number

Date of Application

Date of MC Approval

Police Check completed

Code of Conduct Signed

Photo ID Card issued

Consent to use photos

SSN Policy for Member Vehicles:

To limit vicarious liability of the Samford Support Network, and for the protection of SSN Members, SSN Clients and the community, ALL SSN Members (whether they drive Clients for the SSN or not) who use a car are required to have an open drivers licence and only use roadworthy vehicles covered by a Comprehensive Vehicle Insurance Policy and are currently registered. Third Party Only insurance cover is not acceptable to be an SSN Member with a car.

If you are an SSN Driver (of Clients), are you willing to drive >25kms each way?
	Vehicle 1	Vehicle 2	Vehicle 3
Car Registration Number
Car insurance type (Note: Comprehensive insurance is required.)
Insurance expiry date
Details last updated:

First Aid Training expiry date

(Note: This is optional and not a requirement to become a Member.)

QAS CPR Awareness date

(Note: This is optional and not a requirement to become a Member.)

Skills and Experience

Fully COVID Vaccinated?

(Note: This is optional and not a requirement to become a Member.)

Date of latest Vax update

(Note: This is optional and not a requirement to become a Member.)

Emergency Contact first and last name

Emergency Contact Address 1

Emergency Contact Address 2

Emergency Contact Suburb

Emergency Contact Postcode

Emergency Contact Home phone

Emergency Contact Work phone

Emergency Contact Mobile phone

Emergency Contact email

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