Name:
Address:
Postcode:
Telephone No./s:
Email Address:
Date of Birth:
If you suffer from any medical conditions, or allergic reactions that you feel may affect your work as a Black to Green Project volunteer, please specify condition and any relevant treatment/medication:
Please give an emergency contact, for use in the unlikely event of an accident whilst you are volunteering:
Name:
Telephone No./s:
YOUR INTEREST IN BLACK TO GREEN
Let us know what type of volunteering activities you are interested in (please tick):
Wildlife / Practical conservation tasks / Education projects / Shadowing / mentoring
Walks / access / Woodland management / Craft / creative activities / Publicity / social media
Local heritage / Being part of the Heart of the Forest Forum / Events management / Other
(please detail below)
………………………………………………………………………………………………………………………………………………………………………………………………………………………
If you would like to be kept informed about Black to Green Project events, activities and news, please tick the box:MONITORING INFORMATION
To provide evidence to our funding bodies and inform our project evaluation, we need to gather some data. Please let us know your ethnic origin (please tick):
White / 1.English/Welsh/
Scottish/Northern Irish/British / Asian/Asian British / 9. Indian / Other ethnic group / 17. Arab
2. Irish / 10. Pakistani / 18. Any other ethnic group
3. Gypsy or Irish Traveller / 11. Bangladeshi
4. Any other White background / 12. Chinese
Mixed/
Multiple ethnic groups / 5. White and Black Caribbean / 13. Any other Asian background
6. White and Black African / Black/
African/ Caribbean/ Black British / 14. African
7. White and Asian / 15. Caribbean
8. Any other Mixed/Multiple ethnic background / 16. Any other Black/African/ Caribbean background
Do you consider yourself to have a disability (please tick):
Yes / No
YOUR DATA
Completing this form enables us to contact you and support you as a volunteer. The information will be kept at the Leicestershire & Rutland Wildlife Trust Office and National Forest Company Offices, and only issued to appropriate staff or volunteer leaders. Your details will be treated as confidential and will not be passed on to any other organisation.
In order to protect your right to confidentiality, the Data Protection Act 1998 set rules for processing personal information. The volunteer data we hold will be shared between The Leicestershire & Rutland Wildlife Trust and The National Forest Company only, and is collected for administrative and insurance purposes, for reporting and statistical analysis and to allow both parties to contact you with matters of interest. The information will not be used for any other purpose.
Your signature……………………………………………………………………………Date of registration…………………………
Please hand this form to the Black to Green Team or return it to:
Ben Devine -Leicestershire & Rutland Wildlife Trust,
The Old Mill, 9 Soar Lane, Leicester,
Leicestershire LE3 5DE
Tel: 0116 262 9968 / Jo Mardell -
The National Forest Company,
Bath Yard, Moira, Swadlincote,
Derbyshire DE12 6BA
Tel: 01283 554239
Thank you for completing this form and offering your time and skills in support of the Leicestershire & Rutland Wildlife Trust and The National Forest Company.