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Form updated: Feb 2015
Form 4
LAY PASTORAL MINISTER (LPM) APPLICATION
TO BE COMPLETED BY THE PARISH PRIEST Applicant’s Details:
Last Name: ......................................................................... Given Names: .........................................................................
Previous, maiden or alternatives names (if applicable): .........................................................................................................
Date of Birth: .................. / ................... / ......................... Parish: ....................................................................................
Mailing Address: .................................................................................................................................................................
Contact Phone: ................................................................. Email: .....................................................................................
Previous Archbishop’s licence held in Perth? Year (if known): .....................................................................
Applicant’s Duties:
Please indicate the duties for which this Licence is required:
Assisting in the administration of Holy Communion
Reading and conducting authorised services of the Church
Pastoral visiting (including ministry with children or youth)
Preaching on occasion as requested by the priest(Proof of qualifications to be submitted with application)
Any other lay ministry authorised by the Archbishop, please list below:
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Applicant has fulfilled the following requirements: (See Policy 45: Screenings)
Volunteer or National Police Clearance (For Volunteer National Police Clearance application please see Form 4 cover pack and send in with applicant’s form) An original or certified copy of a current clearance has been sighted - ‘current’ means not more than 3 years old
Please provide current details Notice No.: ....................................................................... Expiry date: .........................................
‘Working With Children Check’ All LPMs are required to hold a current Working With Children Check
Please provide current details Notice No.: ....................................................................... Expiry date: .........................................
ChurchSafe Workshop has been attended by applicant Date attended: ..........................................................................
Introductory Training Day has been attended by applicant Date attended:...........................................................................
Identification: The applicant’s passport or photo driver’s licence has been sighted ID No: .............................................
Referee(s) have been contacted - attach evidence (ie telephone script) to Form 1 and keep in parish
Please make the applicant aware that:
Limitations may be placed on the licence at the Archbishop’s discretion
There is an expectation to attend annual conference/training days
Supporting signatories:
We the undersigned support this application for a Lay Pastoral Minister Licence within the Diocese of Perth
Parish Priest: ....................................................................... ........................................................................ Date: ……. / ..….. / ……. (Print Name) (Signature)
Warden 1: ........................................................................... ........................................................................ Date: ……. / ..….. / ……. (Print Name) (Signature)
Warden 2: ........................................................................... ........................................................................ Date: ……. / ..….. / ……. (Print Name) (Signature)
Please forward completed form to: The Archbishop’s Registrar, Anglican Diocese of Perth GPO Box W2067, PERTH WA 6846 Tel: (08) 9325 7455 Fax: (08) 9325 6741 OR SCAN AND EMAIL TO [email protected]
REGISTRAR FOR OFFICE USE ONLY
The above named applicant be licensed as a LAY PASTORAL MINISTER for a period of three years from the date below
Signature: ............................................................................................................................................................................ Date: ……. / ..….. / …….
YES / NO
YES / NO
Policy 40.4 Appendix 1
FORM 1 – Volunteer Safe Ministry Application
The Anglican Diocese of Perth is committed to providing safe worshipping environments for everyone especially children and vulnerable people. As part of that commitment, it is a requirement that this form is completed by anyone listed in the addendum. Once completed, this form should be sent to the Director of Professional Standards for processing. A copy will be retained by the Parish.
NB: For any volunteer position requiring an Archbishop’s Licence (such as a Lay Pastoral Minister), a separate cover sheet should also be completed by the Rector / Priest in Charge and Church Wardens. Refer Forms 4 and 4A
Personal Information PARISH: ……………………………………………………………………… Sex: M / F (Please circle)
Surname: …...........................................................…...........…………… Marital Status: ....................................
Given Names: ..............................................................…………........... Date of Birth: …..…. / …..…. / …..….
Previous Name (if applicable): ................................................................................................................................
Preferred Postal Address : ......................................................................................................................................
...........................................................................……………................... Postcode: ...........................................
Tel(h): ....................….……........................................... Tel(w): .........................................................................
Email: ....................….……........................................... Mobile: .........................................................................
Volunteer Role - Before being appointed within the Parish, a person to be considered will have attended for at least 12 months.
Which volunteer role are you seeking in the Parish ? ............................................................................................
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Previous Parish / Church Involvement
Have you been involved with another Parish during the past 5 years?
Name of Parish :………………………………………………………………………………….
How long have you attended this Parish? ………………………………… If less than 5 years, please list all Parishes attended in the past 5 years …………………………………………………………………………………………………………………………………………………………………………
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Referees (Form 8 available from the Diocesan website may be used for these Reference Checks.)
Referees:
1. Senior Church Leader – (Church Warden or Parish Councillor - Not your Rector.)
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If in the Parish for less than 12 months, please provide contact details for a a second Church leader as a referee
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2. Previous positions held in the Anglican Church
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YES / NO
Privacy Statement - Personal information collected by the Anglican Diocese of Perth will only be used for the purposes of determining your suitability as a Church Worker. If you would like to access your personal information you can do this by contacting the Diocesan Registrar on 9325 7455.
Working with Children Check Will this role in the Parish involve working with children?
In Western Australia, employees and volunteers who are actively involved in ‘child-related work’ are required to have a Working with Children (WWC) Check. If you have a WWC Check, please attach a photocopy of your card to this application. If you do not have a current WWCC, you have a legal obligation to obtain one before commencing volunteer work. Information is available from www.checkwwc.wa.gov.au or the Professional Standards Unit.
Suitability to work with Children and Vulnerable People
Have you ever been charged or convicted of any offences involving children?
Have you ever been cautioned or counselled for behaviour that may have been considered inappropriate? If you have been convicted of any offence or you have answered YES to either of the above questions, you must inform the Director of Professional Standards on 9425 7203 or [email protected] before commencing any volunteer role in the Diocese. This information will assist the Church to manage risk and the extent of your involvement in the Parish.
Police Clearances
All volunteers in this Diocese will need to provide one of the following police clearances: Volunteer Police Clearance - application forms are available from the Diocesan website or your Parish, OR A copy of a recent (not more than 18 months old) National Police Clearance, OR Evidence of another type of police clearance, such as one undertaken by the Education Department.
NB - It is a requirement to renew your Volunteer police clearance every three years. Suitability to Transport Parishioners - If it is a requirement that you need to transport people in a motor vehicle, you must provide a copy of your Drivers Licence and declare any traffic infringements or convictions you have received.
Declaration
I confirm that the information I have supplied on this form is true and correct.
I agree that representatives of the Church may contact referees mentioned in this application
I agree to release from any liability any person or organisation that provides information.
I also agree to release from any liability the Church, its officers, church workers and volunteers in relation to this application or information contained herein.
I agree that any decision made in relation to this application is final and I will abide by that decision
Applicant’s Signature: ........................................... Witnessed by: ...................................................... (Parish Priest or Warden)
Name: .................................................................. Name: .................................................................
Date: …..…. / …..…. / …..…. Date: …..…. / …..…. / …..….
YES / NO
Copy attached?
YES / NO
YES / NO
YES / NO
ADDENDUM TO FORM 1 – Volunteer Safe Ministry Application DEFINITIONS: Church – means The Anglican Church of Australia within the Diocese Church Worker – means any person who is or who at any relevant time was: 1. a member of clergy (including the Dean of the Cathedral) whether or not holding the
Archbishop’s Licence or Permission to Officiate; 2. employed or engaged by a Church authority or Church entity; or 3. holding a position or performing a function whether voluntary or for payment with the actual
or apparent authority of a Church authority or Church entity, but excludes the Archbishop Diocese – means The Diocese of Perth. Parish – means a Geographical Worshipping Community; and, where the context permits, and Worshipping Community. Volunteer – means a person aged 18 or more years who is not a Church worker and who: 1. holds a voluntary role, office or position in a congregation or parish or in the Cathedral; or 2. holds otherwise any specific voluntary role, office or position in the Parish with the actual or
apparent authority of the Church. Those required to complete Form 1 - Volunteer Safe Ministry Application are: 1. Churchwardens 2. Parish Councillors 3. Synod Representatives 4. Lay Pastoral Ministers 5. Prayer Group leaders 6. Leaders of Bible study or home groups 7. Leader of a choir or music director 8. Youth leader or youth worker 9. Sunday school teachers 10. Ministry team leaders 11. Welcomers 12. All who work in Op Shops or Parish Cafes
Form 7
REFERENCE CHECK TELEPHONE SCRIPT
Page 1 of 2 Ref: Form 7 - Ref Chk Tel Script v2015
Applicant’s Details:
Name: ........................................................................... Position applied for: ..............................................
Referee Contacted: ...................................................... Relationship: ..........................................................
Telephone No: .............................................................. Date: …. / …. / ….
Reference Checked by: .................................................
Reference Check Guidelines:
a. Introduce yourself and provide background information about why you are calling.
b. Advise information will be treated confidentially.
c. Establish referee’s relationship to applicant: .........................................................................................
d. How long has referee known the applicant? ..........................................................................................
1. How do you think the applicant is suited to the role they seek in this organisation? Would youappoint them to this role?
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2. Please comment on the strengths of the applicant.
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3. Have you ever seen the applicant deal with a difficult situation and, if so, how did they manage it?
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4. Everyone has aspects of themselves which they need to develop or modify. Please comment on areasin which this applicant may need to grow or develop.
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Telephone Script - General Reference Check
Page 2 of 2 Ref: Form 7 - Ref Chk Tel Script v2015
[Please note - The following questions focus on child protection issues]
5. Please comment on the applicant’s skills and characteristics that would make them suitable to leadand/or care for children or young people.
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6. Please describe your experience of the applicant in situations involving the care and safety of childrenor young people.
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7. To your knowledge has the applicant ever engaged in any inappropriate behaviour or what might bedeemed abuse?
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8. How strongly would you recommend this person as a suitable person to care for and / or lead childrenor young people?
[ ] Not at all
[ ] With reservations
[ ] Neither Yes or No
[ ] Recommend
[ ] Strongly recommend
[ ] Don’t Know / Can’t say
9. Is there any other relevant information that you think we should know about the applicant? .........................................................................................................................................................................
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Comments from interviewer
Referee’s level of enthusiasm for applicant? (please circle) HIGH MEDIUM LOW
Did information flow freely, without hesitation? (please circle) YES NO
Overall impression of referee:
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Reference check completed by: .....................................................................................................................
Signature: .................................................................................... DATE: .…. / ….. / .….
PLEASE KEEP THIS SCRIPT ON FILE WITH THE APPLICANT’S FORM 1
Volunteer National Police Check Application
The WA Police Volunteer National Police Check discloses the applicant’s court outcomes and pending
charges to the volunteer agency in the form of codes. These codes are a reference to the classification of
court outcomes in line with the definitions in the Spent Conviction Act 1988.
VOLUNTEER AGENCY REFERENCE NUMBER
SECTION A: Applicant Details
Primary name/ Surname Given names
Gender Date of Birth
Residential Address
Previous/Alias/Maiden Names
Primary name/ Surname Given names
Place Of Birth
Suburb/Town State Country
Additional Information
Working With Children Card # Motor Drivers Licence #
SECTION B: Consent and Indemnity
I certify that I am the applicant named in this form and all details herein provided by me are true and correct. I consent to
a check of the records of all Australian Police Jurisdictions and to the acknowledgement of the existence of any court
outcomes and/or pending charges being provided to an approved volunteer group.
In consideration of the WA Police releasing an acknowledgement of any court outcomes or pending charges, under this
application, I hereby indemnify the state of WA, its servants and agents including all members of WA Police against all
actions, suits, proceedings, causes of actions, cost, claims and demands whatsoever which may be brought or made
against it or them by anybody or person by reason of or arising out of the reason of any details of any court outcomes and
other information recorded against my name purporting to either relate to or concern me.
Volunteer Signature Date
SECTION C: Volunteer Agency Verification
I have viewed the applicant’s ID documents and verify that the details contained within in this form match the ID.
Volunteer Agency Representative Signature Date
THIS VOLUNTEER NATIONAL POLICE CHECK APPLICATION ALONG WITH ALL COPIES OF ID MUST BE RETAINED IN A SAFE AND
SECURE LOCATION FOR A PERIOD OF 24 MONTHS IN ACCORDANCE WA POLICE AUDITING PROTOCOLS.
Parish of:
For diocesan office use only
SECTION D: Identification Documents
The following identity documents can be used to make up 100 points of ID as per the WA Police National Police Certificate.
Primary documents
ID documents Points
Full Australian Birth Certificate 70
Australian Citizenship Certificate 70
Australian Passport (current or expired within last 2 years)
70
International Passport 70
Secondary documents
Only 1 secondary ID document will attract 40 points, subsequent secondary ID will attract 25 points per item.
Secondary ID with a photo will be accepted as primary ID but only attract the points listed in this table.
ID documents Points
Australian Photo Drivers Licence 40 or 25
Australian Photo Firearms Licence 40 or 25
State or Federal Government Employee Photo Id 40 or 25
Centrelink or Social Security Card 40 or 25
Dept. of Veteran's Affairs Card 40 or 25
Tertiary Education Institution Photo Id 40 or 25
Australian Learner's Permit 40 or 25
Medicare Card 25
Property Lease or Rental Agreement 25
Council or Shire rates notice 25
Property insurance papers 25
Utilities bill (power / phone / mobile / water / gas) 25
Motor vehicle Registration or Insurance 25
Professional or Trade association Card 25
Debit or Credit card's (bankcard, ATM card, visa card, mastercard, etc) 25
Passbook or Statement from Financial Institution 25
A change of name document, such as Marriage Certificate, Divorce Papers, Change of Name Certificate, is required if your ID is in multiple names. Please Note: This document will not contribute to the points score.
Please ensure that the Identificaton is checked and copies are kept securely on parish records
