Link an applicant/cardholder to this organisation
Working with Children (Risk Management and Screening) Act 2000
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.
DJAG 008.V2 JUN17
Valid for lodgement
until 30 June 2018
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Department of Justice and Attorney-General
Blue Card Services
Part A – Cardholder/applicant's details Part B – New child related activity type
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)
D D M M Y Y Y Y
Please indicate the type of child-related activity for the new
or additional organisation:
Volunteer (no payment required)
Student (no payment required)
Paid employee (complete Part C)
Part C – Current application/card details
Please indicate the type of application lodged,
or current card held:
'V' Volunteer or student card (payment required in Part H)
'P' Paid card (no payment required)
'E' Exemption card (no payment required)
Part D – 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 E – 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 employment relates:
Child accommodation services including home stays
Child care (excluding family day care)
Churches, clubs and associations
Education programs conducted outside school
(suspended or excluded students or flexible arrangements
under the Education (General Provisions) Act 2006)
Emergency services cadet program
Family day care
Carer
Adult Member
Regular visitor
Health, counselling and support services
(including disability services)
Licensed care services
Local Government
Paid private teaching, coaching or tutoring
Religious representatives
Residential facilities
School boarding houses
School crossing supervisors
Schools (other than registered teachers and parents)
Sport and active recreation
1
University of Southern Queensland
West Street, Toowoomba
4350
Anita Wheeldon
Coordinator Professional Experience
0 7
4 6 3 1 2 3 5 9
professional.experience@usq.edu.au
2
DJAG 008.V2 JUN17
Applicant’s name
Part F – Cardholder/applicant's declaration
I declare that:
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 am proposing to start or continue in regulated employment;
I am not entitled to an exemption;
• I understand my organisation will be advised whether or
not I have a current application for, or hold a current blue/
exemption card; the outcome of this application which may
include whether my application is withdrawn, or a negative
notice issued, or if my blue/exemption card is subsequently
suspended or cancelled;
I understand and will comply with my blue/exemption card
obligations as a blue/exemption card applicant/cardholder; and
I consent to confirmation of the validity of my card being
published or provided.
Signature of applicant/cardholder
Full name of applicant/cardholder
Date of signature
Part G – Organisation/employer declaration
I declare that:
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 am authorised to submit this form on behalf of the
organisation;
the blue/exemption card holder/applicant is proposing to start
or continue in regulated employment with the organisation
listed in Part D;
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 representative
Name of representative
Position of representative
Date of signature
Privacy notice
The Working with Children (Risk Management and Screening) Act 2000 allows the collection of personal information to assess your
eligibility to be issued with a blue/exemption card. Information will be provided to Queensland Police, and may be provided to police,
courts, prosecuting authorities or other authorised agencies as part of the screening process. Information may also be given to:
certain disciplinary bodies to obtain relevant disciplinary information; and/or
your employer, any supervisory body, or other person you have authorised to discuss your application on your behalf.
Personal information will only be provided to other persons or agencies with your permission or where required by law.
For more information about the blue card system and your obligations go to www.bluecard.qld.gov.au.
D D M M Y Y Y Y
D D M M Y Y Y Y
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
3
DJAG 008.V2 JUN17
-
Fax
Part H – 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.
An $87.20 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
To avoid delays in processing, please attach a copy of the receipt when paying by credit card and ensure all applicant details
match those on this form.
Cash or EFTPOS (over the counter transaction only)
Cheque/Money order—made payable to Blue Card Services (ABN 60 789 586 626)
Postal address for receipt (must be completed if the receipt is to be sent to someone other than the applicant)
Postcode
Email address for receipt
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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