DBS Link sent:
DBS Link sent back:
Evidence checked:
DBS completed:
Interview Date:
Volunteer Befriender Application Form
Title: / Name:Address:
Postcode:
Tel. No.: / Mobile No.:
Date of Birth: / Ethnicity:
Email address:
Where did you see the Volunteer opportunity advertised?
Are you a car driver? YES/NO
Are you prepared to travel a short distance to a client’s house if they live slightly outside your immediate area? (N.B. travel expenses are paid). Please tick:
□ Yes, I have access to a car and could travel
□ Yes, I could use public transport
□ No
When would you be available to volunteer? (Please tick box)
MON / TUES / WED / THURS / FRI / SAT / SUN
AM / PM / AM / PM / AM / PM / AM / PM / AM / PM / AM / PM / AM / PM
What was it about the role of Volunteer Befriender that interested you?
Would you be interested in befriending clients who have memory problems or early stages of Dementia (training will be provided) YES/NO
Do you have any experience (personal or work) of volunteering or working with elderly people?
Do you have any specialist skills, interests or hobbies that you could bring to the role?
Equal Opportunities – We welcome volunteer applicants with a range of abilities for the skills they bring. We aim to create a positive environment that enables all volunteers to realise their full potential. So we can consider any appropriate adjustments to the volunteer environment and better support you in your role, please give details of any disabilities or health issues:-
REHABILITATION OF OFFENDERS ACT 1974 AND EXCEPTION ORDER 1975 Because of the nature of the voluntary role for which you are applying, you must provide information about any criminal record. This includes convictions, cautions, reprimands and final warnings. Our power to require this lies in the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975, which removes the normal operation of the Act in relation to specific occupations, including the provision of Home Care Services. In the event of being engaged in connection with this application, any failure to disclose such convictions could result in your being asked to leave.
If you have no convictions please write NONE ______
If you do have any previous or outstanding convictions, cautions, reprimands or final warning, you will be asked to supply details of the type of offence, date, sentence, fine etc after you have returned this form.
Having a conviction will not necessarily stop you from volunteering, but will need to be taken into consideration when assessing your suitability
Can you provide the names of 2 people who will provide a reference, preferably 1 from a work environment
Name: / Name:Address: / Address:
Postcode: / Postcode:
Tel. No.: / Tel. No.:
Email Address: / Email Address:
In what capacity are you known to this person? / In what capacity are you known to this person?
How long have they known you? / How long have they known you?
Information about visas – If you are from the European Union, you are free to volunteer in the UK. For those outside the EU, you will need to check that your visa allows you to volunteer. We advise that you contact the UK Borders and Immigration Agency to find out.
Your details will be kept in accordance with the Data Protection Act 1998/2003. They will be held securely and confidentiality. They will only be accessed by authorised management.
I declare the information I have provided is true.
Signed: / Date:Please return form to Lynda Munns, Volunteer Coordinator at the address below
Crossroads Care South East London, Pier Road Centre, 42 Pier Road, Erith, Kent, DA8 1TA
Tel No.: 01322 336086 Mobile Tel. No.: 07903 043363
E-mail: Website: www.crossroadscaresoutheastlondon.org.uk
Registered with Care Quality Commission, Charity No. 1076375, Company No. 3726471
Registered Name: Bexley Crossroads Care Ltd