Application Form / OFFICE USE ONLY
Date Received:
Date Inputted:
In Progress
Paperwork Complete
Active
Newsletter Only
Volunteer Details
Name:
Address:
Postcode:
Landline phone no:
Mobile: E-mail:
Are you happy to be contacted via email (eg. to receive our newsletter)?
Date of birth:
What sort of volunteering opportunity are you interested in, please refer to the Westbank Information Sheet in your application pack?
What would you like to achieve through your volunteering role?(please tick all that apply)
to develop an interest / to fill my spare time
to give something back to the community / to help with my rehabilitation
to increase my employability / to use my skills and experience
to meet people / make new friends / to learn new skills
to increase my confidence and self-esteem / to get more involved in my community
Other:
Are you available on a regular basis? (Please tick appropriate boxes)
Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
Morning
Afternoon
Evening
Do you have your own transport?Yes / No
Can we call upon you at short notice? Yes / No
Skills and Interests
Please tell us about any interests, skills, hobbies or experience which you feel may be relevant
Criminal Convictions: Because of the nature of our work, you are required by the Rehabilitation of Offenders Act 1974 to declare all unspent criminal convictions, cautions, reprimands or warnings. Please detail below or write ‘none’:
(Having a police record does not necessarily mean that you cannot do voluntary work. However, in order to seek voluntary opportunities with this organisation it is essential that you declare any convictions).Who should we contact in the event of an emergency? / Which GP surgery are you registered with?
Name:
Relationship to you:
Telephone number: / Surgery name:
GP name if known:
Telephone number:
References
Because you may come in to contact with people who are particularly vulnerable, we ask you to give the names of two referees. Referees should be someone who knows you well but is not related to you. It should be someone who can tell us what sort of person you are and about your suitability as a volunteer. Ideally you will have known them formore than two years. One of them needs to be somebody who knows you in a professional capacity (eg. employer, GP, college tutor, social worker)
Reference 1
Name:
Address (postal or email):
Telephone:
How do you know this person?
Reference 2
Name:Address (postal or email):
Telephone:
How do you know this person?
Monitoring
We aim to involve people from a range of backgrounds and it is important that we monitor whether we are achieving this. In addition, we have to provide anonymous, statistical information to our funders. Please fill in this additional information in order that we can ensure we meet our Equal Opportunities policy, help us identify how we may be able to recruit more volunteers in the future and satisfy our funding requirements.
What is your gender? Male FemaleAre you…… (Please tick all that apply)
Employed (full time) / Employed (part time) / Self-employed
Retired / A carer / A former carer
Unemployed / Long-term sick / disabled / Full time parent
Student / Other (please specify):
What is your ethnic origin?(Please tick)
White UK / White European / African Caribbean
Bangladeshi / Chinese / Indian
Pakistani / Other (please specify)
Do you consider yourself to have a disability or impairment? Yes No
Prefer not to say
Is there anything we need to be aware of in order to support/enable you to volunteer with us?:
Do you have any of these long-term conditions?(Please tick all that apply)
Arthritis / Chronic kidney disease / Coronary heart disease
Depression / Diabetes / High blood pressure
High cholesterol / ME / Mobility problems
Multiple sclerosis / Neurological disorder / Pre-diabetes
Respiratory condition / Stroke / Prefer not to say
Other (please specify):
Where did you hear about this voluntary opportunity?(Please tick)
Doctor / Newspaper appeal / Radio appeal
Westbank Charity Shop / CVS / Volunteer Centre /
School / college / Newsletter (please tell us which one)
Word of mouth / friend / Poster / leaflet (please tell us where)
Other (please specify) / Talk / speaker (please tell us where)
Support Agency (which one)
Declaration
Please read the following statements and sign only if you agree with all four.
1)I understand that Westbank Community Health and Care will hold and process my information under the terms and conditions of the Data Protection Act 1998. The reason we ask for this information is in order that: we can make contact with you about existing and future activities you might be involved with; so that we can supply statistical information to our funders about the groups of people we are engaging with where relevant; and so that we can take steps to ensure volunteers are matched appropriately with volunteering opportunities. Only anonymous statistical information will be supplied to authorised agencies such as the Big Lottery Fund and statutory agencies such as the NHS. We also want to evaluate our services and to do so we will share personal data with specially approved organisations (including the Nuffield Trust and the Health and Social Care Information Centre). Other anonymous statistical information will be supplied to authorised agencies such as the Big Lottery Fund and statutory agencies such as the NHS. Any personal information will only be disclosed with your consent.
2)I agree to the people whose names I have given, being contacted for references and understand that the information given by me or the people supplying references will remain confidential to the Volunteering Department at Westbank.
3)I have no objection to the carrying out of a police check (DBS) on me
4)I declare that the information I have given in this application is true and accurate. I understand that failure to provide such information may result in my not being accepted as a volunteer and that by supplying false information my position as a volunteer may be terminated immediately.
Signed:Date:
Drivers
Please complete this section only if you wish to be a volunteer driver.
Do you have a current UK Driving Licence? Yes / No
Have you got any endorsements on your licence? Yes / No
If Yes please give details:
Car make& model: / No of
Doors: / Registration
Number:
Is the car registered in your name? Yes / No
Month Road Tax is due for renewal:
Do you have a current MOT Certificate? Yes / No
(You will be asked to show this if you car is over three years old)
Is your insurance (please tick): 3rd Party Fully Comprehensive
Month insurance is due for renewal:
Name of Insurance Company:
It is essential that volunteers inform their insurance company that they are insuring their car for volunteer activity (you will be given a form to send to your insurance company). You should not be asked to pay an increase in the premium as you are not considered to be driving for profit. If you do not tell your insurance company you that are driving others in a voluntary capacity and you have an accident, your policy can be invalidated and you could be held personally responsible for any damage or injuries sustained.
Are you able / willing to drive someone requiring a wheelchair? Yes / No
Do you have breakdown assistance? Yes / No
For Office Use Only
Insurance form sent: (Date)ID CardInsurance form received:(Date)Donations envelope
MOT CertificateMaps
Driving Licence
Tax
1
Form updated March 2014