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Part D – Category of child related activity (to be completed by the organisation)
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
Health, counselling and support services
employment relates:
(including disability services)
Child accommodation services including home stays
Licensed care services
Child care
Non-State Schools/independent school (other than
registered teachers and parents)
Sta member of an education and care or QEC
service (e.g. long day care, outside school hours care,
Paid private teaching, coaching or tutoring
kindergarten, occasional care, limited hours care)
~
Religious representatives
Other (e.g. nanny, babysitter)
Residential facilities
Churches, clubs and associations
School boarding houses
Education programs conducted outside school (suspended
School crossing supervisors
or excluded students or flexible arrangements under the
Schools, other than EQ sta or volunteers (e.g. P&C,
cleaner)*
Education (General Provisions) Act )
Emergency services cadet program
Sport and active recreation
Family day care
~ If you apply under this category, information about your
Educator
blue card status may be provided to certain regulatory,
Paid assistant
supervisory or governing bodies.
Address where family day care is being provided:
*EQ staff or volunteers working at a school must complete
form 068.
Postcode
Part E – Cardholder/applicant's declaration Part F – Organisation/employer declaration
I declare that:
I declare that:
• the details provided in this form are true and correct;
• the details provided in this form are true and correct;
• I understand it is an oence to provide a false or misleading
statement or document;
• I understand it is an oence to provide a false or misleading
statement or document;
• I am authorised to submit this form on behalf of the
organisation;
• I am proposing to start or continue in regulated employment;
• I am not entitled to an exemption; and
• the blue/exemption card holder/applicant is proposing to start
•
I understand that I must notify Blue Card Services within
or continue in regulated employment with the organisation
14 days if I change my name, contact details, or my child-related
listed in Part C;
employment ends.
• an exemption does not apply;
• I have either:
checked the name, date of birth and signature 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 applicant/cardholder
Full name of applicant/cardholder
Signature of representative
Date of signature
D D M M Y Y Y Y
Name of representative
Position of representative
Date of signature
D D M M Y Y Y Y
Applicant’s name
2
