Personal Details

Details of your children:

Driver's Licence Details

Details of Previous Employers

Employer One

Employer Two

Employer Three

List Two Current Referees (if employed, please provide your current employer)

Previous Volunteer/Work Experience

Physical/Health History

Please Read - Important

Section 79 of the Workers’ Compensation and Rehabilitation Act 1981 “Where it is proved that the worker has, at the time of seeking or entering employment in respect of which he/she claims compensation for a disability, wilfully and falsely represented themselves as not having previously suffered from disability, a dispute resolution body may in its discretion refuse to award compensation which otherwise would be payable”. Please specify any pre-existing medical conditions/injuries/workers’ compensation claims which may affect your ability to undertake the work for which you have applied:

Are you required to take medication which may:

Your preferences in caring for a child / young person:

Do you have a current WA “C” class driver’s license and access to a suitable and roadworthy car at all times?

Do you own a car?

If either of the applicants have children:

Working with Children Check

If no, you will need to apply for one as part of the assessment process. Further information can be found at WWC -

If either of the applicants have children


In signing this Application for a Carer Position, I acknowledge that any misrepresentation of facts is sufficient for dismissal.


Privacy Statement The type of information collected and retained by the organisation includes personal information, including sensitive information about Holiday Host applicants. The organisation's primary purpose of collection is to assess the applicant. The organisation has a system to protect the personal information it retains and, should an application be unsuccessful, all information pertaining to the applicant is destroyed within 30 days

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