Register as a Volunteer

First Name
Last Name
Gender
Date of Birth	(eg. 23-MAR-1965)

Email
Home Phone
Work Phone
Mobile Phone

Street No.
Street Name
District
Suburb

Referee:

We may need to confirm a volunteers suitability for certain tasks by speaking to a referee. Suitable referees may be organisers of local community groups or service clubs, churches, or JPs. If you are able to provide a referee, please enter their details here.

Organisation:	Name:	Phone:

Recent police check:

We may need to confirm a volunteers suitability for certain tasks by completing a police check. If you have had a recent police check as part of some other role you perform, please provide the details of the party who obtained the police check so we can contact them.

Organisation:	Name:	Phone:

I speak this foreign language
I have had flu this year
I am generally available	with these limitations
I wish to be excluded from working directly with flu patients
I have my own transport
I consent to a NZ Police Check

Who can access my information when I register?

Information collected on the volunteer self-registration website will be used by those health, local authority, civil defence and other volunteers coordinating a response to the current pandemic threat. Information will be stored securely.

Please indicate whether you are willing to be contacted for future events other than the swine flu threat.

Canterbury Primary Pandemic Group

Register as a Volunteer