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DJAG 008.V4 MAR19
Valid for lodgement
until 31 March 2020
Link an applicant/cardholder to this organisation
Working with Children (Risk Management and Screening) Act 
This form is to be completed by applicants/cardholders who have applied for, or hold a blue/exemption card to advise they
are undertaking child-related activities with a new or additional organisation.
Part A – Cardholder/applicant's details
1 Family name
2 First name
3 Middle name
4 Date of birth
5 Current postal address
Postcode
6 Telephone
7 Mobile
8 Email
9 Card number (if known)
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
Part B – New child related activity type
Please indicate the type of child-related activity for the new or additional organisation:
Volunteer (no payment required) Student (no payment required) Paid employee (payment required if
currently hold aVcard)
Department of Justice and Attorney-General
Blue Card Services
D D M M Y Y Y Y
James Cook University
DTHM Placements, Building 41, Room 018
Douglas QLD
4811
Lisa Murray
0 7
4 7 8 1 4 6 9 7
dthmplacements@jcu.edu.au
DJAG 008.V4 MAR19
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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 oence to provide a false or misleading
statement or document;
I understand it is an oence 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
Pre-Placement Assistant
DJAG 008.V4 MAR19
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Fax
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  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.
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
Part G – Payment options
The application fee is GST exempt (under division 81), non refundable and subject to change.
i
Payment is NOT required for current 'P' or 'E' card holders.
A $92.30 fee is required where a volunteer applicant/blue cardholder is proposing to undertake child-related activities in a
paid capacity. Upon lodgement and processing of this form, a paid (P) card will be issued (provided there has been no change
to eligibility) which can be used for any other child-related activity being provided (paid or unpaid). Please select one of the
following payment methods:
Credit card—complete payment online at www.bluecard.qld.gov.au
Receipt number Date payment made
Cash or EFTPOS (over the counter transaction only)
Cheque/Money order—made payable to Blue Card Services (ABN 60 789 586 626)
D D M M Y Y Y Y
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
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