SAAS-Staffordshire Adults Autistic Society
Volunteer Registration
Title ...... First Name ...... Surname ......
Preferred Name ...... National Insurance Number ......
Address ......
Town ...... County ...... Post Code ......
Tel. (daytime) ...... Mobile No......
Tel. (evening) ...... Email ......
How did you hear about us?
Another volunteer / Bus advertising / ConnexionsFriend or Relative / GP (Doctor) / Internet
Job Centre / Library / Leaflet or Poster
Media / Publicity / Newspaper / Next Step
Passing by / Radio / School or College
Supermarket display / Support agency / Telephone directory
Voluntary organisation / Volunteers Week
Website (please specify):
Other (please specify):
What are your reasons for volunteering?
Social / InterestGive something back / Use my time usefully
Gain work experience / Gain new skills
Build confidence / Improve health
Improve employment prospects
Other (please state)
Previous Work / Voluntary Work
(Any information you feel will help us to find an appropriate opportunity for you):
ü Tick any of the following that interest you.
Tick at least one box in each list
Areas of Interest / Type of ActivityAnimals / Administration
Art and Culture / Advice Work, Information and Support
Children / Architecture and Building Work
Disability / Art
Disaster Relief / Befriending and Buddying
Domestic Violence / Business and Management, Research
Drugs and Addictions / Campaigning and Lobbying
Education and Literacy / Caring
Elderly / Catering
Emergency Services / Community Work
Employment / Computers, Technology and Website
Environment / Counselling
Families / Driving
Gay, Lesbian, Bi and Transsexual / Employee and Group Volunteering
Health and Hospitals and Hospices / Entertainment
Heritage / Finance Work
Homelessness and Housing / First Aid
Human and Civil Rights / Fundraising
International Aid / Gardening
Legal Aid and Justice / General and Helping
Mental Health / Hostel Work
Mentoring / Languages
Millennium Volunteers (replaced by v) / Legal Work
Museums / Local Events
Music / Marketing, PR and Media
Politics / Mentoring
Prisoners and Ex-Offenders / Music
Race and Ethnicity and Refugees / National and International Events
Religion / Officials
Sport and Outdoor Activities / Practical Work and DIY
Women’s groups / Retail and Charity shops
Youth / Sports Development
Teaching, Training and Coaching
Trusteeship and Committee Work
Under 16 volunteering
Youth work
Yes / No
Are you interested in one-off volunteering?
Availability
(Please tick each box when you could be available as a volunteer)
Sat
/ Sun / Mon / Tue / Wed / Thu / FriAM
PM
EVE
How much time each week would you like to spend?
Not specific / 1-2 hours / 2-4 hours4-6 hours / 6-8 hours / Up to 10 hours
Over 10 hours / Not regular hours
Do you have any special requirements that need to be taken into account when finding you an opportunity? (e.g. Access requirements etc.)
No / Yes / (if Yes please give details)Driving
No / YesDo you have a full Driving Licence?
Do you have your own transport?
How old are you? (please tick)
Under 15 q / 16/17 q 18-19 q / 19-25 q / 26-29 q30-34 q / 35-39 q / 40-44 q / 45-49 q
50-54 q / 55-59 q / 60-64 q / Over 65 q
Date of Birth ...... /...... /......
Declaration
I understand that references and / or police or health checks may be taken before I am offered voluntary work. I understand that for some driving opportunities a full clean licence may be required.
To the best of my knowledge the information given on this form is correct. I understand that the information provided will be used by third parties for monitoring and statistical research purposes only and that all personal data will be processed in line with the Data Protection Act 1998.
Name: Signature: Date:Name: Signature: Date:
[On behalf of the Project]