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1 Office for Ministry Development Anglican Diocese of Newcastle Application Received: CA Approved: LLA Approved: AP Approved: Application for a new Licence or for the Renewal of a Licence as a Chalice Assistant Lay Liturgical Assistant or for Authority to Preach in the Local Congregation Safe Ministry Checks: Licence Number: Licence Date: CRM Updated: Sharepoint Updated: SECTION A: YOUR NAME, PARISH AND APPLICATION DETAILS to be completed by the applicant: Title First name Middle names Surname Your Parish Licences for Chalice Assistants, Lay Liturgical Assistants and persons with Authority to Preach in the Local Congregation are issued by the Bishop for an initial period of three years. Licences may be renewed for further periods of three years. Applicants for a new licence or for the renewal of a licence should complete and return this form together with the documentation detailed in Section H. The following ministries are authorised by each licence: Chalice Assistant Ministry of administering the Chalice in the presence of a priest at Holy Communion services in the parish. Lay Liturgical Assistant Ministry of administering the Chalice in the presence of a priest at Holy Communion services in the parish, and any of the following: (i) ministry of leading a Service of the Word according to an authorised rite in the parish in the absence of a priest, (ii) taking the Reserved Sacrament to the sick and elderly in their homes in the parish in the absence of a priest, (iii) additional ministries as agreed. Authority to Preach in the Local Congregation Ministry of preaching in a local congregation. Which licence are you applying for? (delete as applicable) Chalice Assistant Lay Liturgical Assistant Authority to Preach in the Local Congregation Is this application for a new licence or for the renewal of an existing licence? (delete as applicable) New Licence (do not complete Section E of this form) Renewal (do not complete Section D of this form)

2 SECTION B: RESPONSIBILITIES AND DUTIES to be completed by the parish priest: Holders of a Lay Liturgical Assistant licence do not also need a Chalice Assistant licence. Applicants for Authority to Preach in the Local Congregation must have completed the Bishop s Certificate in Theology for Ministry or an equivalent qualification. FOR CHALICE ASSISTANT APPLICATION OR RENEWAL: Section 1 Administer the Chalice in the presence of a priest at Holy Communion services in the parish. FOR LAY LITURGICAL ASSISTANT APPLICATION OR RENEWAL: Administer the Chalice in the presence of a priest at Holy Communion services in the parish, AND Section 2 Lead a Service of the Word according to an authorised rite in the parish in the absence of a priest. Section 3 Take the Reserved Sacrament to the sick and elderly in their homes in the parish in the absence of a priest. Section 4 The following additional ministry duties: FOR AUTHORITY TO PREACH IN THE LOCAL CONGREGATION APPLICATION OR RENEWAL: Section 5 Preach in the local congregation, having completed the Bishop s Certificate in Theology for Ministry or an equivalent qualification. Please detail the relevant theological qualifications that you have completed:

3 SECTION C: INFORMATION ABOUT YOU to be completed by the applicant: Home address Mailing address if different Telephone number (h) Telephone number (w) Telephone number (m) address Your date and place of baptism Your date and place of confirmation or reception Have you ever had criminal proceedings brought against you, or are criminal proceedings against you currently pending? Your date of birth Your Current Employment Yes / No (if yes please provide details on a separate sheet) Please indicate courses of study related to Theology and Ministry which you have successfully completed: (for example: EfM, Bishop s Certificate or Diploma, Trinity Certificate, BTheol.) Chalice Assistants and Lay Liturgical Assistants are encouraged to participate in a ministry skills stream each year. Are you willing to make an ongoing commitment to training and formation over the next three years, including participation in a skills stream? If so, please provide details of your intentions:

4 SECTION D: TO BE COMPLETED BY APPLICANTS FOR A NEW LICENCE to be completed by the applicant: Describe your Christian journey: How will being licenced for this ministry benefit God s mission in your parish?

5 Why are you an Anglican? SECTION E: TO BE COMPLETED BY APPLICANTS FOR THE RENEWAL OF A LICENCE Describe your ministry activities relating to your current licence over the last three years:

6 How will continuing to be licenced for this ministry benefit God s mission in your parish? Describe the training and formation that you have undertaken over the last three years:

7 SECTION F: NOMINATION BY THE CHURCH WARDENS to be completed by the church wardens: We hereby nominate the above to be authorised for the ministry responsibilities detailed in Section B. Signature Signature Signature Name and date Name and date Name and date SECTION G: NOMINATION BY THE PARISH PRIEST to be completed by the parish priest: As Rector / Priest in Charge / Locum Tenens / Other: of the Parish of I do hereby nominate the above to be authorised for the ministry responsibilities detailed in Section B, and certify that to the best of my knowledge the particulars supplied are accurate and that the applicant is sufficiently instructed in the doctrine and discipline of the Anglican Church and qualified by education and natural gifts and the confidence of the parishioners to fulfil this ministry to the edification of the Family of God. Please provide your reasons for nominating this person: Signature Name and date

8 SECTION H: STATEMENT BY THE APPLICANT to be completed by the applicant: I declare that I have been baptised and confirmed or received and that I am a regular communicant in the Anglican Church of Australia. I believe the doctrine of the Anglican Church of Australia as expressed in the 39 Articles of Religion, the Book of Common Prayer and the Ordering of Bishops, Priests and Deacons to be agreeable to the Word of God. I promise to conform in my ministry to such regulations as are or may be laid down by the Bishop of the Diocese; to carry out the instructions of the Parish Priest of the Parish; to endeavour to promote peace and unity in the Parish, and to conduct myself as becomes a worker for Christ, for the good of his Church and for the spiritual welfare of others. I further promise to cease from the exercise of my ministry should I be required to do so by the Bishop. I understand that I am required to attend safe ministry training every three years and to be familiar with, and abide by, the code of conduct Faithfulness in Service. I confirm that to the best of my knowledge the particulars supplied by me in this application form are accurate. IMPORTANT: DO NOT SUBMIT THIS FORM WITHOUT ALSO ENCLOSING THE FOLLOWING DOCUMENTATION For all applications (both for new licences and renewals) you must include: Working with Children Safe Ministry Check ( Applicant Declaration and Consent ); A clear photocopy of identification totalling 100 points (from the list provided below) must be enclosed with the form. This photocopy should be signed by your Parish Priest to confirm that your Priest has sighted the original documents. The identification documents are securely destroyed immediately after verification. Additionally, for applications seeking the renewal of a licence you must include: Your current ministry licence. PLEASE RETURN THIS FORM AND THE ADDITIONAL DOCUMENTATION TO Diocesan Ministry Development Officer Anglican Diocese of Newcastle, P. O. Box 817, Newcastle NSW 2300

9 APPLICANT DECLARATION AND CONSENT Personal Details: An easier way? Complete this form online at check.kids.nsw.gov.au Family name: First name: Other given name(s): Previous names/aliases: Family name: First name: Other given name(s): Residential address: Address Line 1: Address Line 2: Suburb/Town: State: Postcode: Country: Phone: Mobile: Date of birth: Gender: Place of birth: Suburb/Town: State: Country: Identifying document: If you used one of these documents to verify your identity, please fill in these details Licence Type: Driver's License Firearms License Licence number: Issuing Agency: Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia Australian Army Commonwealth of Australia Defence Force Academy Australian Navy Australian RAAF Issued by a country other than Australia Other Passport Type: Private Government UN Refugee Issuing Country: Passport number: Position applied for: Title: Type: It is an offence for a prohibited person to apply for, attempt to obtain, undertake, or remain in child-related employment, or to sign this declaration, unless applying to care for a relative child as defined by section 33PA of the Commission for Children and Young People Act A prohibited person is a person who is convicted of the following (whether in NSW or elsewhere): murder of a child serious sex offence, including carnal knowledge child-related personal violence offence (an offence committed by an adult involving intentionally wounding or causing grievous bodily harm to a child) indecency offences punishable by imprisonment of 12 months or more kidnapping (unless the offender is or has been the child's parent or carer) offences connected with child prostitution possession, distribution or publication of child pornography, or attempt, conspiracy or incitement to commit the above offences. 17/08/2012

10 A prohibited person includes a Registrable person under the Child Protection (Offenders Registration) Act A conviction includes a finding that the charge for an offence is proven, or that a person is guilty of an offence, even though the court does not proceed to a conviction. Details of these offences can be found online at Working With Children Employer Guidelines Fact Sheet 1. Prohibited Employment Declaration I declare that I am not a prohibited person under the Commission for Children and Young People Act 1998 and I understand that it is an offence for a prohibited person to seek child-related employment. I declare that while I am a prohibited person under the Commission for Children and Young People Act 1998, I am applying to care for a child related to me (as defined by section 33PA of the Act). Declaration and consent I am the applicant named in this form. All information in this form, and identification documents provided for this application, are true and correct. I understand that if I have provided false or misleading information it may result in a decision not to employ me, or, if already employed, may lead to my dismissal. I have not omitted any names or aliases that I use or used in the past. I have read and understood the contents of this form and the relevant information in the Working With Children Employer Guidelines. I am aware that if considered for child-related employment, several checks will be undertaken to ascertain my suitability, including: 1. National criminal record check for charges and/or convictions (including spent convictions) for: any sexual offence (including but not limited to, sexual assault, acts of indecency, child pornography, child prostitution and carnal knowledge); any child-related personal violence offence; any assault, ill treatment or neglect of, or psychological harm to a child and any registrable offence punishable by imprisonment for 12 months or more. I understand that this check includes convictions or charges that: may not have been heard or finalised by a court; or are proven but have not led to a conviction; or have been dismissed, withdrawn or discharged by a court. 2. Check for relevant Apprehended Violence Orders taken out by a police officer or other public official for the protection of a child or children; and 3. Check for relevant employment proceedings notified to the Commission for Children and Young People under the Commission for Children and Young People Act I consent to these checks being conducted and consent to the Commission for Children and Young People, or an Approved Screening Agency, obtaining any relevant record identified by these checks and any additional information relating to that record from sources such as courts, police, prosecutors and past employers, to enable a full and informed estimate of risk. I consent to these sources disclosing information relating to that record to the Commission for Children and Young People or Approved Screening Agency. I acknowledge that: the information obtained during the Working With Children background check, including this consent, may be collected and used by and/or disclosed to the Commission for Children and Young People, or an Approved Screening Agency, for the purposes of the Working With Children Check; the Commission for Children and Young People and Approved Screening Agencies may share the information obtained during the Working With Children background check for the purposes of the Working With Children Check; the outcome of an estimate of risk will be provided to my prospective employer or their employer-related body; my relevant records will not be released to my current or prospective employers; any information obtained as part of this process may be used by Australian Police Services for law enforcement purposes, including the investigation of any outstanding criminal offences; and the information provided may be referred to the Commission for Children and Young People and/or to NSW Police for law enforcement purposes and for monitoring and auditing compliance with the procedures and standards for the Working With Children Check in accordance with Section 36 (1)(f) of the Commission for Children and Young People Act Signature: Date: What should I do next? Once you have completed your details you will need to sign the printed form and provide the signed form to your prospective employer/volunteer organisation. You may also wish to retain a copy for your records. gov.au/handler/background check consents/print form/print 17/08/2012