Personal details

Name
Address
Postcode
Tel no / Mobile
Email / Date of Birth

Details of someone to contact In case of an emergency

Name / Tel no

Volunteer Opportunities – We have a wide variety of roles available (please refer to Volunteer Role Descriptions document). Please tell us here which roles you maybe interested in e.g Befriender, Silver Surfer Tutor, Information and Advice Volunteer

or

If you have a skill, hobby or interest you would like to share please describe:

Please indicate what days and times you are available

Monday / Times available
Tuesday / Times available
Wednesday / Times available
Thursday / Times available
Friday / Times available
Saturday / Times available
Sunday / Times available

Employment/volunteering experience - do not be concerned if you have not been employed or undertaken any voluntary work before

Details of relevant skills, hobbies or interests


Referees

We require two references, one of which must be from a professional, e.g., organisations you have previously worked for or assisted in a voluntary capacity, teacher; solicitor; etc. We are unable to accept references from relatives and/or friends.

a) / Name: / b) / Name:
Organisation: / Organisation:
Address: / Address:
Tel. No / Tel. No
Email: / Email:
In what capacity do you know this person? / In what capacity do you know this person?

Criminal Convictions

Have you ever been convicted of a criminal offence, have convictions pending or made subject to an order under the Mental Health Acts (Section 41)? Yes No

If Yes, please give details. A prior or pending criminal conviction will not necessarily prevent you from volunteering with us, but failure to disclose relevant information will result in immediate dismissal. This information will be kept in the strictest confidence.

______

Do you have a Criminal Record Bureau/Disclosure and Barring Service Check Yes No

If Yes, what date was the check carried out ______

Health

Is there anything we need to know regarding your health which you think may affect the types of volunteer duties you can do? Yes No If Yes, please describe:

______

Where/how did you hear about Age UK Waltham Forest?______

I wish to apply as a volunteer and confirm that all the information given is correct

Signature ______Date ______

Please return to FREEPOST RSRH-BJSY-CLHB E17 3PW

Tel 020 8558 5512, Fax 020 8558 0383, E-mail:

Reg Charity No. 1048212