Registration Form

REGISTRATION FORM CARE WISELY

*Title

*First Name

Middle Name

*Last Name

*Gender

*Date of Birth

*Mobile

*Email

*Attach your photo

Address Information

Unit No

*Street No

*Street Name

*Suburb

*State

*Postcode

*Residential Status:

Australian Citizen
Australian Permanent Resident
Working Visa
Temporary Resident Visa
Student Visa

Primary Documents

Attach Australian/International Passport

Attach Australian Birth Certificate

*Secondary Documents

Attach Australian Driving Licence

Attach Working with children certificate

Attach Australian Citizenship certificate

Attach Australian Medicare card

Attach International Driving Licence

Photo ID

Attach Australian/International Passport

Attach Driving Licence

Emergency Contact Information

*Full Name

Relationship

*Mobile Phone Number

Home Phone Number

Referee 1 Information

*Referee 1 Name

*Referee 1 CompanyName

*Referee 1 Position

Referee 1 Relationship

*Referee 1 Mobile

Referee 2 Information

*Referee 2 Name

*Referee 2 CompanyName

*Referee 2 Position

Referee 2 Relationship

*Referee 2 Mobile

Bank Account Information

*Account Name

*Bank Name

*BSB

*Account Number

Tax File Number Declaration Information

*Tax File Number

*On what basis are you paid?
Full-time employment
Part-time employment
Labour hire
Superannuation or annuity income stream
Casual employment

*Are you:
An Australian resident for tax purposes
A foreign resident for tax purposes
A working holiday maker

*Do you want to claim the tax-free threshold from this payer?

Only claim the tax‑free threshold from one payer at a time, unless your total income from all sources for the financial year will be less than the tax‑free threshold.

Yes No

Answer no here if you are a foreign resident or working holiday maker, except if you are a foreign resident in receipt of an Australian Government pension or allowance

*Do you have a Higher Education Loan Program (HELP), VET Student Loan (VSL), Financial Supplement (FS), Student Start-up Loan (SSL) or Trade Support Loan (TSL) debt? Yes No

Your payer will withhold additional amounts to cover any compulsory Yes repayment that may be raised on your notice of assessment.

Super Fund Information

DO NOT HAVE OWN SUPER ACCOUNT

*Super Account Name

*Super Fund Name

*Super Membership Number

*Super Fund Address

*Super Phone No

*Super Website

*Super Fund ABN

*Super Fund USI

*Police Check Information

Attach Australian Police Clearance certificate

*Mandatory Competencies and Training

Attach CPR certificate valid within the last year

Attach Qualifications certification such as Certificate III in Aged Care OR Bachelor of Nursing

Attach AHPRA registration number (Nurses only)

Attach Up to date vaccinations (Flu)

Attach Up to date vaccinations (COVID)

NDIS Number:

*What is your main method of transport? Car Public Transport

*How far are you prepared to travel for work?

*Medical History

To assist us to comply with our obligation to ensure a safe workplace and in order to enable us to determine whether applicants are able to safely and adequately perform duties required by the position, please provide details of any previous or current injuries, illnesses or disabilities of which you are aware and which you believe may affect your ability to carry out the requirements of the position. (Victoria only: Failure to provide such information may constitute a breach of section 82(7) of the Accident Compensation Act 1985(Vic) and according to section 82(3) of the Act may result in any aggravation etc of the injury arising out of the employment not qualifying for compensation under legislation.)

* Do you have any physical disabilities, medical conditions or previous injuries which may affect your ability to perform your work duties?

Yes

If yes please give details:

* Do you have an intellectual disability that may affect your ability to perform your work duties?

Yes

If yes please give details:

VACCINATIONS: Please select the appropriate box for the below vaccinations

COVID Vax		Flu Vax
Y	N	Y	N

Have you previously been injured at work? Y/N

Yes

Are you currently receiving any medical attention from a doctor or anyone else? If so, please give details

Yes

Have you ever experienced or been treated for any of the following conditions?
	Y	N		Y	N		Y	N
Eye Trouble			Hearing Impairment			Surgical Procedures
Asthma			Hernia			Duodenal Ulcer
Deafness			Epilepsy			Lung Disorder
Fainting/Blackout			Back trouble/disorder			Nerve Disorders
Dizziness			Arthritis			Injury (any body part) give details:
Swollen Joints			Chronic Illnesses
Skin Trouble			Diabetes

AUTHORITY TO REPRESENT

What your personal information is:Personal information is any information or an opinion (whether true or not) about you. It may range from the very sensitive (eg. medical history or condition) to the everyday (eg. address and phone number). It would include the opinions of others about your work performance (whether true or not), your work experience and qualifications, aptitude test results and other information obtained by us in connection with your possible work placements.

Who will be collecting your personal information?

Your personal information will be collected by Carewisely Nursing Agency and used to assist us in determining your suitability for work placements. If you wish to contact us about your personal or sensitive information you should contact us during normal business hours which are 8:30am to 5:30pm.

How your information will be collected: Personal information will be collected from you directly when you fill out and submit one of our registration forms or any other information in connection with your application to us for registration. Personal information will also be collected when:

- we receive any reference about you - we receive the results of any competency or medical test - we receive performance feedback (whether positive or negative) - we receive any complaint from or about you in the workplace - we receive any information about a workplace accident in which you are involved - we receive any information about any insurance investigation, litigation, registration or professional disciplinary matter, criminal matter, inquest or inquiry in which you are involved - you provide us with any additional information about you

Your information will be used: Your personal information may be used in connection with: - your actual or possible work placement - your performance appraisals - our assessment of your ongoing performance and prospects - any test or assessment (including medical tests and assessments) that you might be required to undergo - our identification of your training needs - any workplace rehabilitation - our management of any complaint, investigation or inquiry in which you are involved - any insurance claim or proposal that requires disclosure of your personal information

Your personal information may be disclosed to: - potential and actual employers and clients of Carewisely Nursing Agency - referees - other member organizations of the Carewisely Nursing Agency - our insurers - a professional association or registration body that has a proper interest in the disclosure of your personal information - a workers compensation body - our contractors and suppliers (eg. IT contractors and database designers) - any person with a lawful entitlement to obtain the information

You can gain access to your personal information that we hold: Under privacy legislation you have a right to see any personal information about you that we may hold. If you are able to establish that any of the information that we hold about you is not accurate, complete and up to date we will take reasonable steps to correct this.

Storage and Security Carewisely Nursing Agency take all reasonable steps to ensure that information held in paper or electronic form is secure, and that it is protected from misuse, loss, unauthorized access, modification or disclosure. All staff at Carewisely Nursing Agency will take reasonable steps to ensure that personal information is only used for recruitment purposes or disclosed to other organisations to the extent necessary for our business purposes. When personal information is no longer required it will be destroyed.

I have read the above and understand that Carewisely Nursing Agency will collect my personal information and use this in order to represent me to potential and actual employers and clients for the purposes of finding me work placements.

Candidate Signature

I have read and agree to the T&C and privacy policy: