Volunteer Application Form

CONFIDENTIAL

Mr.Mrs.Miss.Ms.(circle one)Gender:Male Female(circle one)

First name: ……………………………………………………………………………………………..

Surname: ……………………………………………………………………………………………….

Address: ………………………………………………………………………………………………..

……………………………………………………………….Post Code: …………………

Telephone: Daytime: ………………………………….. Evening: .…………….………………….

E-mail: ………………………………………………………… Mobile: ……………………………..

Please take a few minutes to look through the following lists. The Areas of Interest and the Activities that you choose help us to match you with volunteering opportunities.

Areas of Interest - Please tick any (3) of the following that Interest you: / Type of Activity - Please tick any (3) of the following that Interest you:

Administration

/ Befriending and Buddying
Children and Youth / Caring
Disability / Computers, Technology and Website
Employee and Group Volunteering / Fundraising
Languages / Local Events
Marketing and PR and Media / Mentoring
National and International Events / Teaching, Training and Coaching
Trusteeship and Committee Work / Advocacy

Please give brief details of any previous voluntary work, paid work experience, qualifications, skills etc. (Please continue on a separate sheet if necessary)

Please tick each box when you could be available as a volunteer. How many hours would you be able to commit to a volunteer role each week?

Mon / Tues / Wed / Thu / Fri / Sat / Sun

AM

PM
EVE

Date of birth: …………………………………………… (for Insurance purposes)

Are you in good health?Yes No 

Have you had any illness in the last 1 – 2 Years?

If YES, please give brief details

Have you ever been convicted of any offence?Yes No 

(If the voluntary work involves helping with children/young people/vulnerable adults, all criminal offences must be declared and are exempt from the provision of the Rehabilitation of Offenders Act 1974)

If YES, please give details:

Which age group are you in? (tick one)

/ What is your current employment status? (tick one)
15-18 / Carer
19-25 / Non employed
26-29 / Houseperson
30-34 / Retired
35-39 / Student
40-44 / Unable to work
45-49 / Unemployed
50-54 / Employed
55-59
60-64
Over 65
Under 15

Which ethnic group do you feel you belong in? (tick one)

White British

/ Indian
White British (English) / Pakistani
White British (Scottish) / Bangladeshi
White British (Welsh) / Other Asian background
White Irish / Black Caribbean
Other White background / Black African
White & Black Caribbean / Other Black background
White & Black African / Chinese
White & Asian / Any other background
Other Mixed background

Are you disabled?YesNo(Please Circle)

If YES, are you:Registered (with your GP)Self Classifying

Is there anything else you would like to tell us about yourself?

References: Name and address of two responsible people who have known you for over two years and are not members of your family, to whom we might apply for a reference.

Name ……………………………………..Name ……………………………………..

Address …………………………………..Address …………………………………..

……………………………………………..……………………………………………..

……………………………………………..……………………………………………..

Telephone No ……………………………Telephone No ……………………………

Occupation ………………………………Occupation ………………………………

Data Protection:

These records are confidential to Crossroads Care - South Thames. You are entitled to inspect any record we keep about you. No information will be passed on without your consent to a third party.

Signature: ……………………………………… Date: ………………………………………

Please return your form to: Carers Hub Lambeth, Brixton Office, 336 Brixton Road, SW9 7AA.

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