LW Volunteer Application - Police Vetting & LW COE Form

As part of completing this form, you will need the following information.
• Drivers License Number (If Applicable)

NZ Police Vetting Service and Consent Form

This form is for the collection of the required information for Launchpad and Lifewalk volunteers to enable a NZ Police check to be carried out.
It contains all the same information as the Manual Version of the form NZPVS-07/23

A Guide for the Police Vetting Form

Kia Ora,
To help simplify the process of completing your Police Vetting form, please refer to the instructions below:
• Section 1 is included for your information & informed consent.
• Sections 2 & 3 need to be completed by you.
• Police Vetting must be completed every three years.
• Police Vets can take upto six weeks to be processed
• All documentation held by Launchpad and Lifewalk remains confidential.
• You cannot go into a school on behalf of Launchpad or Lifewalk until the police vet has been completed.

For further information, please see the Guide to Completing the Consent Form.

Persons name *

First name

Last name

Email address

If no email address is entered here we are unable to communicate with you easily in regards to this Police Vetting request. In the case where you do not have an email address, please ensure you put in a contact phone number.

Contact phone *

To get started, press Next.

Form Page Break #1

Vetting Service Request & Consent Form

Section 1: Approved Agency to complete

For more information please see the Guide to Completing the Consent Form

https://www.police.govt.nz/sites/default/files/publications/user-guide-to-pvs-vetting-request-consent-form.pdf

1.1 Name of agency submitting vetting request
The Churches Education Commission

1.2 Name of the person being vetted

1.3 Description of the role of the person being vetted *

This is a brief description of the role (not the job title). This is used by Police to help decide what type of vet is conducted if it is unclear from the following questions.

1.4 Which groups will the person being vetted be working with (select all that apply): *

Children/ Young People

Vulnerable Adults

1.5 Does the role involve caring for people in the home of the person being vetted? *

This is about whether the person being vetted is providing services out of their own home (that is, are vulnerable children or adults visiting the home of the person being vetted for support).

Yes

1.6 Is the person being vetted: *

A paid worker

A volunteer

Undertaking vocational or educational training

1.7 Is the person being vetted a Children’s Worker according to the Children’s Act 2014, section 23(1)? *

If the person being vetted is not working with children/ young people (Q 1.4), tick ‘No’ then skip to question 1.11. If the person being vetted IS working with children (Q 1.4) AND is a volunteer (Q 1.6), tick ‘No’ then skip to question 1.9.

Yes

No (skip to question 1.9)

1.8 Is the role of the person being vetted a core or non-core worker role according to the Children’s Act 2014, section 23(1)?

Core worker

Non-core worker

1.9 Has the person being vetted previously been Police vetted by your agency? *

Yes

No (skip to question 1.11)

1.10 Is the person being vetted still working in the role for which your agency last obtained a Police vet?

If this request is a renewal of the person’s previous vet for this role, please select Yes. Otherwise, answer no.

Yes

No – the person being vetted is applying for a new role or position

1.11 What is the job title of the person being vetted? *

1.12 Evidence of identity (to be completed by agency representative or identity referee)

See consent form guide for details on how to complete this section

A primary ID has been sighted (mandatory) *

A secondary ID has been sighted (mandatory) *

One form of ID is photographic (mandatory) *

Evidence of name change has been sighted (if applicable) *

In making this request, I confirm that:
• I have complied and will comply with the Approved Agency Agreement.
• I am satisfied as to the identity of the person being vetted.
• I have obtained the authorisation of the person being vetted to submit this vetting request as set out in section 3 of this form.

View the Approved Agency Agreement

Agency Representative:
Name: Grace Drollét-Maoate

Date *

Electronic Signature *

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Section 2: Person being vetted to complete and return to agency

2.1 Personal Information
Note: the name you are most commonly known by is your primary name

Family name (Primary): *

First/Middle name(s) *

Gender *

Date of Birth *

Place of Birth: (Town/City/State)

Country of Birth *

NZ Driver Licence number:

2.2 Previous names if applicable
Please include other alias or alternate names; married name if not your primary name; previous/ maiden/ name changed by deed poll or statutory declaration. Please include ALL names (first, middle and last) for each alias/previous name.

Family Name

First Name

Middle Names

+ Add

- Remove

2.3 Permanent residential address *

Address line 1

Address line 2

Address line 3

Address line 4

Town/Suburb

City

Postcode/Zip

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Section 3: Person being vetted to complete and return to agency

3.1 Consent to release information

1. The New Zealand Police may release any information they hold if relevant to the purpose of this vetting request. This includes:
a. Conviction histories and infringement/demerit reports.
b. Active investigations, charges and warrants to arrest.
c. Charges that did not result in a conviction including those that were acquitted (not guilty), dischargedwithout conviction or withdrawn.
d. Any interaction I have had with New Zealand Police relevant to the role being vetted, includinginvestigations that did not result in prosecution or were resolved by an alternative resolution programme.
e. Information regarding family violence where I was the victim, offender or witness to an incident or offence.This is particularly relevant where the role being vetted for takes place in a home environment whereexposure to physical or verbal violence could place vulnerable persons at emotional or physical risk.
f. Information subject to name suppression where that information is necessary for the purpose of the vet.

2. If I am eligible under the Criminal Records (Clean Slate) Act 2004, my conviction history will not be released unless:
a. Section 19(3) of the Clean Slate Act applies to this request (exceptions to the clean slate regime).
b. Section 31(3) of the Children’s Act 2014 applies to this request (safety checks of core children’s workers).
c. The vetting request is made for the purpose of an overseas visa/work permit and authorises the vettingreport to be provided directly to the relevant embassy, high commission, or consulate.
Please see the vetting website for more information regarding the Clean Slate legislation and what may be released.

3. The Police Vetting Service may disclose newly obtained relevant information to the requesting agency after thecompletion of the Police vet in the following circumstances:
a. The disclosure of the newly obtained information is justified under the Privacy Act 2020 (if it had existed orbeen available at the time of the Police vet, it would have been disclosed); and
b. The Police Vetting Service has taken steps to confirm that the purpose for the Police vet still exists – e.g.,that I am employed or engaged in a role that required a Police vet.
The Police Vetting Service will take reasonable steps to notify you prior to the disclosure.

4. Information provided in this consent form may be used to update New Zealand Police records.

5. I am entitled to a copy of the vetting report released to the agency (to be provided by the agency) and can request a correction of any personal information by contacting the Police Vetting Service.

6. Please notify the agency or the Police Vetting Service if you wish to withdraw your consent.

For further information about the vetting process, please see the vetting website.

Authorisation of person being vetted:
• I confirm that the information I have provided in this form relates to me and is correct.
• I have read and understood the information above.
• I authorise New Zealand Police to disclose any personal information relevant to my application (as described above) to the agency making this request for the purpose of assessing my suitability.

I have read and understood the information above and consent accordingly. I understand this is an electronic signature. *

Full Name *

Date *

Have you ever lived in Australia? *

Yes

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Section 4: Applicant to complete for Australian check (if required)

Additional Personal Information (for Australian National Police History Check)

Last Permanent Australian Residential Address

Flat/Number/Street: *

Suburb *

City/Town/Rural District *

Postcode *

State or Territory *

Period of Residence (Start Date) *

Period of Residence (End Date) *

Australian Driver's license Number (If applicable)

License Issued By

Australian Firearms License No (If applicable)

License issued by

General Information for an Australian National Police History Check

General Information

Australian Criminal Intelligence Commission (ACIC) is collecting your personal information in this form in order to conduct a National Police History Check (NPHC) on you. Approved Agencies in New Zealand, named in section one, use the personal information collected on this form and the resulting NPHC as part of the assessment process to determine suitability for the position/entitlement/benefit which you are applying for.
Unless statutory obligations require otherwise, the information provided on this form will not be used without your prior consent for any purpose other than in relation to the assessment of your suitability or to maintain the records of ACIC, Australian Police Agencies, (Australian Federal Police, ACT Policing, The New South Wales Police Force, Queensland Police Service, South Australia Police, Victoria Police, Western Australia Police, Northern Territory Police Force, Tasmania Police Service) or NZ Police.
You will be required to complete another consent form for any future NPHC checks.

National Police History Check (NPHC)

A NPHC is an integral part of the assessment of your suitability. Information on this form will be used by ACIC, and Australian Police Agencies for checking action; it will also be used to update records held about you by ACIC, Australian Police Agencies and NZ Police.
Information released may include outstanding charges, warrant information and criminal convictions/findings/pleas of guilt recorded against you that may be disclosed according to the laws of the relevant jurisdiction and, in the absence of any laws governing the release of that information, according to the relevant jurisdiction information release policy.

Limitations on accuracy and use of Police History Information

While every care has been taken by ACIC to conduct a search of information held by Australian Police Agencies that relate to the applicant, the accuracy and quality of this NPHC depends on accurate identification of the Applicant (including aliases) according to the information provided in the Request and Consent Form and the comprehensiveness of police records. If the applicant does not complete the information requirements in this form the success and validity of the NPHC will be compromised.
If for any reason you do not agree with the results of your NPHC, please notify the Approved Agency that you submitted the check through in the first instance, so that the NPHC dispute process can be initiated.
The release of information by Australian Police Agencies is subject to relevant Spent Convictions, non-disclosure legislation or information release policies.

Spent Conviction Schemes

The aim of Spent Convictions legislation (Applicable Spent Conviction legislation, as amended from time to time.) is to prevent discrimination based on certain previous convictions. Spent Convictions legislation limits the use and disclosure of older, less serious convictions and findings of guilt. Each Australian Police Agency will apply the relevant Spent Convictions legislation/information release policy prior to disclosure.

The following links may be helpful in sourcing information on Spent Convictions in the Australian States & Territories but may not be relied upon. If further information or clarification is required, please contact the individual Australian Police Agencies directly for further information about their release policies and any legislation that affects them.

Commonwealth

http://www.comlaw.gov.au/

New South Wales

http://www.legislation.nsw.gov.au/

Queensland

http://www.legislation.qld.gov.au/

South Australia

http://www.legislation.sa.gov.au/

Victoria Police

http://www.police.vic.gov.au/

Tasmania

http://www.thelaw.tas.gov.au/

Western Australia

http://www.slp.wa.gov.au/

Northern Territory

http://www.nt.gov.au/dcm/legislation/current.html

Australian Capital Territory

http://www.legislation.act.gov.au/

Provision of incomplete, false or misleading information

An Approved Agency or Applicant must take reasonable steps to ensure that the personal information collected, or disclosed is accurate, complete, and up to date.
You are asked to certify that the personal information you have provided on this form is correct. If it is subsequently discovered, for example as a result of a check of police records, that you have provided incomplete, false or misleading information, you may be assessed as unsuitable.
It is a serious offence to provide false or misleading information in Australia.

Consent to disclosure (for Australian National Police History Check)

1. I have read the General Information in section 3 of this form and understand that information will be disclosed in accordance with applicable legislation and information release policies (including spent convictions legislation, however described) in the Commonwealth, States and Territories;

2. I understand that the position/entitlement for which I am being considered may be in a category for which exclusions from Spent Convictions legislation may apply;

3. I have fully completed this form, and the personal information I have provided in it relates to me, contains my full name and all names previously used by me, and is correct;

4. I acknowledge that the provision of false or misleading information is a serious offence;

5. I acknowledge that the Approved Agency named in Section 1 of this form is collecting information in this Form to provide to New Zealand Police to provide to ACIC (an Agency of the Commonwealth of Australia) and the Australian Police Agencies;

6. I consent to:
a. ACIC using and disclosing personal information about me in this form to the Australian Police Agencies;
b. the Australian Police Agencies disclosing to ACIC, from their records, Police History information that can be disclosed in accordance with the laws of the Commonwealth, States and Territories and in accordance with the relevant jurisdiction’s information release policies;
c. ACIC disclosing the information disclosed by the Australian Police Agencies to New Zealand Police.
d. New Zealand Police disclosing any criminal history information about me to the Approved Agency named in Section 1 of this form to assess my suitability in relation to my application;

7. I acknowledge that any information provided by me in this form relates specifically to the purpose identified in Section 1 of this form;

8. I acknowledge that any information provided by the Australian Police Agencies or ACIC relates specifically to the purpose identified in Section 1 above;

9. I acknowledge that personal information that I provide in this form may be disclosed to the Approved Agency named in Section 1 of this form (including contractors or related bodies corporate) located in New Zealand or overseas.

10. I acknowledge that it is usual practice for an Applicant's personal information in this form to be disclosed to New Zealand Police and Australian Police Agencies for them to use for their respective law enforcement purposes including the investigation of any outstanding criminal offences.

Note: The information provided in this form will be used only for the purpose stated above unless statutory obligations require otherwise.

Applicant’s Authorisation:

I have read and understood the information above and consent accordingly. *

Date *

Signed in electronic form

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Code of Expectations

A Lifewalk Chaplain is a safe, professional volunteer presence in the school; it is a privilege to be invited into a school and therefore we expect all Chaplains to abide by the following Code of Expectations:

1. Become a Lifewalk accredited Chaplain by:
a. Completing the Lifewalk training course
b. Undergoing Police Vetting every three years
c. Completing a Church Endorsement every three years
d. Attend Supervision groups once a term
e. Attend Professional Development workshops annually

2. Lifewalk Chaplaincy Agreement
A Lifewalk chaplain agrees to complete their weekly sessions that have been confirmed with the school. Please notify your school ASAP for any cancellations or changes.

3. Abide by all relevant policies and procedures of the school including disclosure policy

4. Health and Safety Requirements
Ask for a copy of the Health and Safety policies and procedures that are relevant for your role as chaplain in the school. Familiarise yourself with these requirements and review twice a year

5. Respect and Sensitivity.
A Lifewalk Chaplain must show respect and sensitivity towards each student and the school community as set out in the Human Rights Act 1993:
Core protections: The illegal grounds of discrimination. Human Rights Act 1993, s 21. The anti-discrimination laws cover unfair treatment against you because of certain personal characteristics – like gender, race and disability.

6. Confidentiality
A chaplain must maintain student confidentiality, unless a situation of harm is presented, whereby appropriate disclosure is enacted.

7. Appropriate Disclosure
Should a student raise a topic of a serious nature (abortion, suicide, self-harm, eating disorders, violence etc), the Chaplain must inform the appropriate school representative (Principal, Deputy Principal or SENCO) as per the school’s policies and procedures.

8. Lifewalk Vision/Mission/Values
A Lifewalk Chaplain must be familiar with the Vision, Mission and Values of Lifewalk and constantly represent these in their practice.

9. A signed copy of the Code of Expectations will be kept on file at the National Office.

I have read and agree to these Code of Expectations. *

Thank you

Thank you for taking the time to complete these forms. They are an important part of the work you do in your schools.

Please check the highlighted fields