Exemption card application
Working with Children (Risk Management and Screening) Act 2000
This form is to be completed by Queensland registered teachers and Queensland police ocers
proposing to start or continue in child-related employment.
If you are working at a Queensland State School, you must complete the QSS form 067.
Valid for lodgement
until 31 March 2020
E
DJAG 003.V4 MAR19
-
-
Department of Justice and Attorney-General
Blue Card Services
Part A – Exemption status
(to be completed by the applicant)
Part D – Category of child related activity
(to be completed by the organisation)
Please indicate if you are a Queensland:
Registered teacher; or
Police ocer
Record teacher registration/police identification number
Part B – Child related activity details
(to be completed by the organisation)
1 Please select the type of child-related employment for
which a blue card is required:
Paid employee
Volunteer
Student
2 Is this application associated with NDIS?
Yes
No
Part C – Organisation details
(to be completed by the organisation)
1 Name of organisation
2 Organisation ID number (if known)
3 Postal address of organisation
Postcode
4 Contact person’s name
5 Contact person’s position
6 Telephone
7 Email
Information about categories of child-related employment
and whether any exemptions apply is available from
www.bluecard.qld.gov.au.
Please select the type of child-related activity to which the
employment relates:
Child accommodation services including home stays
Child care
Sta member of an education and care or QEC
service (e.g. long day care, outside school hours care,
kindergarten, occasional care, limited hours care)
~
Other (e.g. nanny, babysitter)
Churches, clubs and associations
Education programs conducted outside school
(suspended or excluded students or flexible
arrangements under the Education (General
Provisions) Act )
Emergency services cadet program
Health, counselling and support services
(including disability services)
Licensed care services
Non-State Schools/independent school (other than
registered teachers and parents)
Paid private teaching, coaching or tutoring
Religious representatives
Residential facilities
School boarding houses
School crossing supervisors
Schools, other than EQ sta or volunteers (e.g. P&C,
cleaner)
Sport and active recreation
~ If you apply under this category, information about your
blue card status may be provided to certain regulatory,
supervisory or governing bodies.
Applicant’s name
1
James Cook University - College of Arts, Society and Education
1016271
1 James Cook Drive
James Cook University, QLD
4811
Kate Betridge
Student Placement Officer
0 7
4 7 8 1 4 6 8 1
eduprofex@jcu.edu.au
2
DJAG 003.V4 MAR19
1 Title Mr Mrs Miss Ms
Other
2 Full legal name
Family name
First name
Middle name
No middle name (please tick)
3 Do you have a previous name, or have you been known
by any other name?
Yes (record details below) No
It does not matter how long ago you used the name
or how long the name was used for e.g.
• birth name • name before marriage • married name
• alias • change by certificate • adoption
• changed order of name
Family name
First name
Middle name
If you require more space, please tick this box
and attach a separate list.
4 Gender
5 Date of birth
6 Place of birth
Town/City
State/Territory
Country
7 Current postal address (within Australia)
Postcode
8 Current residential address (if different to above)
Postcode
9 Telephone number
Daytime
Mobile
10 Email
11 Do you identify as? (if applicable)
Aboriginal Torres Strait Islander
Aboriginal and Torres Strait Islander
Prefer not to state
12 Previous blue/exemption card number (if applicable):
/
13 Are you, or have you ever been a: (please tick)
Foster or kinship carer
Health practitioner
Operator/supervisor/carer of a child care
or education service
Teacher
14 Applicant’s declaration
I declare that:
I am the applicant named in this form and have not
omitted any names or aliases that I use or have used
in the past;
the information and identification documents provided
by me for this application are true and correct and I
understand it is an oence to provide a false or misleading
statement or document;
I consent to information from any police, court,
prosecuting authority or other authorised agency being
obtained and for the police, courts, prosecuting authority
or other authorised agency to disclose any information
for the purposes of assessing my eligibility to work with
children including ongoing checks while my application/
exemption card remains current;
I understand that the information obtained includes
but isnot limited to details of convictions
^
and pending
or non-conviction charges* or information on the
circumstances relating to oences committed or allegedly
committed by me, regardless of when and where the
oence or alleged oence occurred;
I am a registered teacher or police ocer proposing
tostart or continue in regulated employment and
am notentitled to an exemption on the basis of that
regulatedemployment; and
I understand and will comply with my blue card
obligations including that I must notify Blue Card Services
within 14 days if I change my name, contact details, or my
child-related employment ends.
Sign inside the box.
Please do not touch or go outside the lines.
Date of signature
Part E – Applicant’s details (to be completed by the applicant)
D D M M Y Y Y Y
D D M M Y Y Y Y
Applicant’s name
3
DJAG 003.V4 MAR19
Part F – Proof of identity (to be completed by the organisation)
The organisation must check two current, original identification documents from the applicant which collectively show the applicant’s
full name, date of birth and signature. The applicant’s details on their identification documents must match the details provided in
Part E.
One of the following combinations must be used: EITHER
List 1
+
List 1
(one must show a signature)
OR
+
List 2
(one must show a signature)
List 1
If one of the valid identification combinations above cannot be provided, complete and attach a ‘Request to consider
alternative identification’ form.
If the applicant resides more than 50km from the organisation or has a disability which aects their mobility, complete and
submit a ‘Confirmation of identity’ form.
Please indicate which identification documents have been sighted by placing a
in the box.
LIST 1
SIGNATURE DOCUMENT
Driver licence/learner permit/proof of age/photo
identification card
Licence/reference No:
Issued in the state of:
Australian Passport (current or expired in the last 2 years)
NON-SIGNATURE DOCUMENT
Birth certificate (or extract)
Proof of Australian citizenship or permanent residency
Overseas Passport (current)
Country of issue:
LIST 2
SIGNATURE DOCUMENT
Pension Concession card/Department of Veterans’ Aairs
Entitlement card/Seniors Health card/Health care card/
any other current financial entitlement card issued by
Department of Human Services.
Credit card or bank card (do not attach copy)
Positive Notice Blue or Exemption card
Student identification card issued by an education
institution (with photo and signature)
Queensland Gaming Machine Licence
NON-SIGNATURE DOCUMENT
Medicare card
Queensland crowd controller/private investigator/
security ocer licence
Passbook or account statement issued by a financial
institution dated in the last 6 months
Australian taxation assessment notice dated in the
last 6 months
Queensland Licence issued under the Weapons Act 1990
If possible, please attach a photocopy of the documents sighted for verification purposes (excluding credit or bank cards).
Part G – Organisation declaration (to be completed by the organisation)
IMPORTANT NOTE: This section must be completed by the organisation's representative irrespective of whether or not the
organisation can sight the identification documents.
I declare that:
I understand that it is an oence to provide a false or misleading statement or document;
I am authorised to submit this application on behalf of the organisation;
the applicant is proposing to start or continue in regulated employment and an exemption does not apply; and
I have either:
checked the details provided in this form and confirmed they match those on the identification documents sighted; or
delegated this responsibility to a prescribed person and have attached the ‘Confirmation of identity’ form.
Signature of representative
Date of signature
Name of representative
Position of representative
D D M M Y Y Y Y
Applicant’s name
DJAG 003.V4 MAR19
Privacy Notice
The Department of Justice and Attorney-General (DJAG) is collecting your personal information under the Working with Children (Risk
Management and Screening) Act 2000 (WWC Act). Where relevant, DJAG will disclose personal information to organisations you work
for or provide services to about whether you have a current application for, or hold a current blue/exemption card; the outcome of this
application which may include its withdrawal or negative notice, or if your blue/exemption card is subsequently suspended or cancelled.
DJAG publishes confirmation about whether your blue card is valid. DJAG will use and disclose your personal information to assess your
application for a blue/exemption card and will disclose your personal information to courts, law enforcement agencies, disciplinary or
supervisory bodies or anyone you have agreed for DJAG to discuss your application with. It may also be used to contact you with more
information about your application and the Blue Card process. DJAG may use electronic communication for matters of information
provision and collection of data for research purposes. Authorised users of the home-based care register, kept pursuant to the WWC Act,
may also have access to your personal information. DJAG manages your personal information in accordance with the WWC Act and the
Information Privacy Act 2009.
Important information
You can withdraw your consent to screening at any time before a decision is made.
A registered teacher means a person registered as a teacher under the Education (Queensland College of Teachers) Act 2005.
A police ocer means a person engaged by the Queensland Police Service as a police ocer under the Police Service Administration Act
1990.
After you have submitted an application for an exemption card, your application details will be forwarded to the Queensland College of
Teachers or the Queensland Police Service, where appropriate.
Confirmation of your status as a registered teacher or police ocer will be sought from the relevant agency and whether there is a need
to undertake further employment screening in relation to your application.
If you have indicated that you are a registered teacher:
The Queensland College of Teachers may only advise that there is a need to undertake further employment screening where the
Queensland College of Teachers is aware of any police information in relation to you.
If you have indicated that you are a police ocer:
The Queensland Police Service may only advise that there is a need to undertake further employment screening about a police ocer
where the Queensland Police Service is aware that the applicant has been charged with an oence and the charge has not been finally
dealt with.
No personal information about the specifics of a person’s criminal history will be provided as part of this information exchange.
*Non-conviction charge means, whether a person was charged as an adult or a child, a charge: that has been withdrawn; that has been
the subject of a nolle prosequi, a no true bill or a submission of no evidence to oer; that led to a conviction that was quashed on
appeal; or upon which a person was acquitted or disposed of by a court otherwise than by way of conviction.
^
Conviction/convicted means a finding of guilt by a court, or the acceptance of a plea of guilty by a court, whether or not a conviction is
recorded and regardless of when and where it occurred.
For more information about the blue card system and your obligations go to www.bluecard.qld.gov.au.
Application lodgement
Applications may be lodged by one of the following methods:
U
Scan and upload
www.bluecard.qld.gov.au/uploadform
By post
PO Box 12671, Brisbane George Street QLD 4003
In person
53 Albert Street, Brisbane QLD 4000
By fax
07 3035 5910
Fax
Blue Card Services, Department of Justice and Attorney-General
U
Scan and upload at www.bluecard.qld.gov.au/uploadform
07 3211 6999 or 1800 113 611
PO Box 12671, Brisbane George Street QLD 4003
07 3035 5910
53 Albert Street, Brisbane QLD 4000
www.bluecard.qld.gov.au
4
Fax
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