WHITE HOUSE CANCER SUPPORT
10 Ednam Road, Dudley, West Midlands DY1 1JX
01384-231232
Registered Charity No.: 1141904
APPLICATION FOR VOLUNTEERING AS A DRIVER
FULL NAME ......
ADDRESS ......
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...... Post Code......
HOME TELEPHONE NUMBER ......
MOBILE TELEPHONE NUMBER ………………………………………….
DAYTIME TELEPHONE NUMBER ......
Present occupation, or last occupation if currently retired or unemployed:
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What days and times are you available to work? Please tick all appropriate boxes –
MON / TUE / WED / THU / FRI / SAT / SUN9.00 -1.00
1.00 –5.00
evening
Comments –
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Please give details of any particular skills, training or experience that you feel make you suitable for the work of patient transport driver:
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Are there any other areas that you would like to work in if suitable training was made available to you?
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Our premises at the White House are on three floors, with limited access for some disabled persons, and assisting patients can involve some lifting and carrying. Do you have any disability or medical condition that you feel that we should take into consideration when allocating duties to you?
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Have you ever been convicted by the courts, or cautioned, reprimanded or given a final warning by the police? (Note that the post you have applied for is excepted from the Rehabilitation of Offenders Act 1974, which means that all convictions, cautions, reprimands and final warnings on your criminal record need to be disclosed, whether or not they are “spent”) YES/NO
(If yes, please give details of offences, penalties and dates – this will not necessarily prevent us from using your services, and the information will be treated in strictest confidence. NOTE: Cancer Support uses the Criminal Records Bureau (CRB) Disclosure Service in assessing the suitability of applicants for positions of trust)
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Please give details of two persons (not immediate relatives) who are in a position to comment on your suitability to work as a volunteer with Cancer Support. It is our practice to take up references in all cases:
1. Name ......
Address ......
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...... Post Code ......
Occupation ...... Phone No......
2. Name ......
Address ......
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...... Post Code......
Occupation ...... Phone No......
Please tell us briefly why you would like to work with Cancer Support, and also give us any further information, which you feel we should have:
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Please sign below –
I confirm that the information given in this application is correct. I understand that there will be an initial probationary period of three months.
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Signature
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Please supply the following information about your vehicle:
Registration Number ………………………………………………..
Make …………………………
Model …………………………
Colour ………………………………..
We shall require to see, and take copies of:
Vehicle ownership document
Driving licence
Insurance Certificate
MOT Certificate (if vehicle over 3 years old)
NOTE: We need to keep up to date copies of these documents. Please let us see any amendments, updates or renewals in due course.
IMPORTANT
YOU must advise your motor insurance company that you will be using your vehicle to provide voluntary unpaid transport on behalf of Cancer Support for cancer patients and/or carers. You are advised to obtain their acknowledgment in the form of an endorsement to the policy, or in a letter. We will require a copy of the letter or endorsement.
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Cs/driver/app.form 01/09