Coventry Enabling Scheme - Application Form

Before you can be registered as a volunteer, we need to have certain information about you. It is therefore important to us, (the Volunteer Co-ordinators / Support Assistants), that we know as much as possible about you to enable us to match your individual and personal skills, to that of the person or group of people you will be supporting.

Your Details

Title……………….. Full Name ………………………………………………………..

Address (including post code) …………………………………………………………

…………………………………………………………

…………………………………………………………

Telephone numbers Home ……………………….………………………………..

Work ……………………..………………………………….

Mobile …………………………………………………………

Email address ………………………………………………………….

Your preferred method of contact ………………………………………………………….

General Information

How did you find out about the Coventry Enabling Scheme? Please tick one box only.

City Council website Information given out

"Word of mouth" Voluntary Action Coventry

Local press

Other? (Please specify) ………………………………………………………………………………….

Preferences

Having read the information on the Coventry Enabling Scheme if at this stage you have a preference for a particular area please make your choice below.

Travel Buddy Community Buddy Work Buddy

Reasons for Volunteering as a Buddy:
Please tell us why you would like to volunteer as a Buddy? What personal qualities, interests or hobbies you would like to bring to the role; and what you hope to gain from the experience?
Please use a separate sheet if necessary.

Commitment:

How much time are you looking to commit to volunteering per week/fortnight?

2 hours ½ day 1 day More than 1 day Week / Fortnight

(Please circle one)

How long are you interested in volunteering for?

6 to 12 months 12 months plus

Availability:

Monday Tuesday Wednesday Thursday Friday

Only during term times Only during holidays

Occasionally through the "Work Buddy" scheme there may be opportunities to volunteer 'out of office hours'. Please tick the occasions where it may be of interest to you:

Evenings Weekends Bank holidays 7.00am – 8:30am

Referees

Give details of two people who may be asked about your ability to act as a volunteer. Your referees must not be relatives; you must have known them for at least two years; and one must be a current/previous employer or other professional, for example teacher, tutor.

Reference 1

Title ______Name ______

Address ______

______

Telephone number ______Position held ______

Context in which known to you

Email address (if known) ______

Reference 2

Title ______Name ______

Address ______

______

Telephone number ______Position held ______

Context in which known to you

Email address (if known) ______

Criminal Convictions

Note: a criminal conviction will not automatically disqualify you from becoming a volunteer

Police Checks:
Have you any criminal convictions? (please tick) / YES NO
If “YES”, please give details

It is a condition of recruitment as a Volunteer that an enhanced criminal record check is carried out prior to selection. (You can find out more information about what this means on: http://www.homeoffice.gov.uk/agencies-public-bodies/crb/ )

If you do not agree to such a check we will not be able to consider your application. Please sign and date below if you agree to this check being carried out.

Signature ______Date______

Do you consider yourself to have a disability – YES NO
The Coventry Enabling Scheme actively welcomes applicants with a range of abilities for the skills they bring. We aim to create a positive environment that enables all individuals to realise their full potential. Please give details of any reasonable adjustments relative to your disability or health condition that will help us to support you in your volunteer role.
Additional Information
If there is any additional information that you would like to relay please detail below

Declaration

Please check that you have answered all questions fully before signing the declaration below.

“I certify that the information given is true and complete to the best of my knowledge and belief.”

Signature: ______Date: ______

Please return your completed application form to:

Coventry Enabling Scheme

Curriers Enterprise

Unit 2, Curriers Close

Charter Avenue Industrial Estate

Canley

Coventry

CV4 8AW

Email:

Web: www.coventry.gov/enable

If you require assistance with completing this form please telephone (024) 7678 6831