Personal Details (Please print)
Title: / Full Name:
Address:
Post Code:
Telephone: / Home:
Work:
Mobile:
E-mail address:
Date of birth:
(will not be taken into consideration for volunteering,for monitoring purpose only)
What type of volunteering work/projects are you most interested in? (please tick)
Advocacy Service / Charity Shop – Gwynedd
Age Well Anglesey(activity centre) / Charity Shop – Anglesey
Age Well Gwynedd (activity centre) / Day Care Centres / Lunch clubs – Gwynedd
Befriending Service - Anglesey (Cadwyn Môn) / Day Care Centres / Lunch clubs – Anglesey
Befriending Service - Gwynedd (Ffrindia’) / Internet / Computer Learning and Support
Cafés / Drop-in Centres / Volunteer Driving
Information and Advice / Benefits / Insurance
Please outline any relevant experience / training / skills / qualifications / interests / hobbies
Availability - please tickto indicate the days and times most suitable for you:
Monday / Tuesday / Wednesday / Thursday / Friday / Weekends
Morning
Afternoon
Evenings
Maximum number of hours you would be available per day / per week / per month?
References
In the interests of yourself and the older people with whom you will be working, we need to obtain a reference from two people who have known you for at least 2 years. These referees must not be family members, or partners you must also not use professionals who are helping you find work for example Job Centre staff. If you have been employed within the last 3 years please give that employer as one of your referees.
Name:
Address:
Post Code:
Tel No:
Relationship to you: / Name:
Address:
Post Code:
Tel No:
Relationship to you:
Rehabilitation of Offenders Act 1974
Your role as a volunteer involves contact with vulnerable older people, so you are required by the Rehabilitation of Offenders Act 1974 to declare all convictions, including spent convictions.
Have you ever been convicted, warned, reprimanded or cautioned
for a criminal offence, or liable in a civil case? (please circle as appropriate) Yes / No
If you have answered ‘Yes’ to the above, please provide details under separate confidential cover.
Disclosure and Barring ServiceChecks
As a volunteer with Age Cymru Gwynedd a Môn, we may require a Disclosure and Barring Service disclosure, depending on your role.
Do you give your permission for Age Cymru Gwynedd a Môn
to carry out a DBS check? (There is no cost involved) Yes / No
Data Protection Act
Information on our database is strictly confidential and we do not pass on any personal data about you to outside organisations and/or individuals without your express personal consent. Please indicate if we may:
Keep basic information from this application form on computer? Yes / No
Send you updates and more information aboutAge Cymru Gwynedd
a Môn? Yes / No
Declaration
I certify that all the information given on this form is correct to the best of my knowledge and belief.
Signed: Date:
Please return this form to:Age Cymru Gwynedd a Môn, 39 Pool St, Caernarfon, Gwynedd LL552AE
23/12/2014