One of Our Strengths Is the Diversity of Our Team. As Part of Our Diversity Policy We

One of our strengths is the diversity of our team. As part of our Diversity Policy we aim to offer equal opportunities to all. The help us monitor the effectiveness of this policy please take a few moments to complete the information below. This information will remain confidential.

Title (Miss/Mrs/Ms/Mr/Dr/Other)

Forenames:Surname:

Address:

Postcode:

Day Telephone number:

Evening Telephone Number:

Mobile:

Email address:

Gender: (please tick)  Female  Male Date of birth: _ _/_ _/_ _ _ _

How would you describe your ethnic group? (please tick)

 British  White and black Caribbean  Indian

 Irish  White and black African  Pakistani
 White and Asian  Bangladeshi

 Other mixed background  Other Asian backgroundOther

Please specify______Please specify______Please specify______

Do you have any particular requirements we will need to consider? (Please provide details)

Do you consider yourself to have, or have had a disability? (Please tick)

 Yes No

If yes, do you consider it would affect your ability to carry out this role according to the role profile?(Please tick)

 Yes  No

If yes, please outline any reasonable adjustment that could be made to assist you in this role.

Do you require a work permit?(Please tick) Yes No

If yes, do you hold a work permit?(Please tick)  Yes  No

If yes, when does it expire?

Have you been convicted of any criminal offences (which haven’t been spent under the Rehabilitation of Offenders Act 1974)?

Yes No

Please give details

Data Protection

The information provided on this form will be recorded confidentially on the Volunteer Database and in your personal file. The information will be used to monitor the effectiveness of our recruitment processes and to produce statistics about our volunteers.

The information will only be used by the Volunteer Services Team (including the Occupational Health Advisor) to monitor broad trends.

In accordance with the Data Protection Act 1998we will not share any of your personal data with external sources without first seeking your permission.