Te Hiranga Tangata / Work and Income

Printed from: https://services.workandincome.govt.nz

Printed: 11 June 2025

Limited Service Volunteer application

About this form

Complete this form if you want to apply to go on the Limited Service Volunteer (LSV) programme.

This form has 2 parts:

  • an application to apply for the course
  • a police vetting form.

Once you've completed both parts, click 'Submit form' at the end.

Please note the questions in this form may change dynamically based on your answers to previous questions.

Keeping a copy of this form

After you submit the form, you’ll see a confirmation page with all the information you entered. If you want to keep a copy, you can print that page or save it as a PDF using the browser’s print function. We can’t provide you with a copy of the form later.

Personal Details

You can find this on your Community Services Card, SuperGold Card or by requesting a client number online

What is your full name?
This is the name you are usually known as. If your name on your birth certificate is different, or if you had a different married name, a name in another language, changed your name by deed poll, or had an alias, please tell us about those as well.
Is your full name the same as the one on your birth certificate? (required)
You must be over 17 years and under 25 years at time of your application.
Ethnicity (optional)We collect this information for research and evaluation of our services. You don't have to answer this question if you don't want to.

Contact Details

If you're not sure what the postcode is for this address, you can find it with the NZ Post postcode finder
This must be a valid New Zealand number.
This must be a valid New Zealand number.

Emergency contact details

If there's an emergency while you're on the course, who would you like us to contact?
e.g. mother, father, partner etc
This must be a valid New Zealand number.
This must be a valid New Zealand number.
If you're not sure what the postcode is for this address, you can find it with the NZ Post postcode finder

Court Appearances

Do you have to appear in Court in the next 6 months? (required)If you have a court appearance in the next 6 months, you may still be able to take part in LSV. It depends on the charge.
Do you know your Court date? (required)
Have you appeared before court on any charge? (required)
You can write up to 500 characters, including spaces.
Have you been given diversion for committing a crime? (required)
Are you currently serving a court imposed sentence or order? (required)
You can write up to 500 characters, including spaces.

LSV Camps

You can nominate a camp you'd like to attend and we'll do our best to match your preferences to the courses that are running.

Ordinarily, trainees go to the camp closest to their home, although this depends on places and dates available. Transport costs to and from the course are free.

Which LSV Camp would you prefer to attend? (required)You can tick more than one option.

Special food needs

Do you have any special food needs or allergies? (required)
What special food needs or allergies do you have? (optional)
You can write up to 250 characters, including spaces.

Reason for applying

We want to make sure LSV is the right programme for you. You can write up to 1,000 characters, including spaces.

Signature

There are some things you need to agree to so you (and others) stay safe and healthy, and are looked after while you're on the LSV programme.

Please make sure you read and understand the information below before you sign this application.

Medical certificate and Police Vetting forms

A medical certificate and police vetting form need to be completed as part of your application.

  • You'll need to make an appointment with your doctor or nurse practitioner so they can complete the medical certificate that goes with this application.
  • The information gathered on the medical certificate is needed so you (and others) can stay safe while you're on the LSV programme.
  • Once the medical certificate is returned to us we'll share it with New Zealand Defence Force (NZDF) personnel so they can provide health support during the LSV programme.
  • The LSV medical certificate will be stored on your MSD record for six months and then deleted.
  • Once you've completed the Police Vetting form, MSD will send it with the rest of your application to NZDF who will forward it to NZ Police.

If you're accepted

If you're accepted onto the LSV programme, you'll need to:

  • follow all instructions for NZDF personnel
  • treat other LSV trainees and NZDF personnel with care and respect
  • tell MSD if you have any changes to any upcoming court dates (or new dates) before you start the course.

If you don't do these things you may be asked to leave the LSV programme early.

Vetting Service - Request and Consent Form for LSV applications

Some answers will pre-fill from the information you've already given us. If you need to change them, go back to the relevant section in this form.

Where were you born?
Do you have a driver licence? (required)

How long have you lived at this address?

Consent to disclosure (for a New Zealand Police Vetting Check)

For further information, go to Vetting Service on NZ Police website

  1. The information about me that NZ Police may consider relevant to my application and release in vetting comprises any conviction history and, for certain agencies, infringement/demerit reports; and it may include other information such as active charges and warrants to arrest, any information received or obtained by NZ Police, and any interaction I have had with NZ Police in any context (including family violence), even where I have not been charged, or charges are withdrawn, or I have been acquitted (not guilty) of a charge, or I have been discharged without conviction.
  2. Any conviction history will be released in accordance with the Criminal Records (Clean Slate) Act 2004; this means that, if I am 'eligible' for clean slate (e.g. no convictions for 7 years, never been to prison, no convictions for specified sexual offending, etc - see section 7 of the Act):
    1. My criminal record of convictions will not be disclosed; but
    2. If the role for which I have applied is an exception to the clean slate scheme (e.g. predominantly involving care and protection of a child or young person), my criminal record of convictions will be disclosed.
  3. When releasing information to non-government Approved Agencies, Police may release the fact, without details, that suppressed information exists in relation to any conviction and, where NZ Police considers it relevant and justified, in relation to any current or past change however it was resolved (e.g. withdrawn, discharged, acquitted).
  4. Where NZ Police holds relevant information that it is unwilling to disclose to the Approved Agency for privacy, confidentiality or law enforcement reasons, NZ Police may recommend against unsupervised access to children or vulnerable persons (this is known as a 'red stamp').
  5. The personal information I provide in the form is being collected for vetting purposes, and may also be used for the purpose of updating NZ Police records
  6. I may withdraw this consent, prior to Police's disclosure of the vetting result, by notifying the Approved Agency who will immediately notify NZ Police to cease the vetting process.
  7. I am entitled to access the vetting result released to the Approved Agency and seek correction of Police information about me in accordance with the Privacy Act 1993. By making a request to the 'Approved Agency' within 20 working days of submitting this 'Request and Consent' form.
  8. No later than twelve months after the release of the vetting result, the Approved Agency will securely dispose of this consent form and copies of identification documents, as well as the vetting result released by NZ Police, unless a longer retention period is required by legislation applying to the Approved Agency.
  9. The information I have provided in this form relates to me and is correct.