Personal Details:

Title: Mr.□Mrs.□Miss.□Ms.□Dr.□Prof.□Rev.□

First Name:*
Surname:*

Gender: Female□ Male□ Prefer not to say□

Date of Birth:* (DD/MM/YYYY) / Contact Number:*
Address Line 1:* / Address Line 2:
Address Line 3: / Postcode:*
Email Address:
Charity Name:*

Security Questions:

First School:* / Place of Birth:*

DBS Details:Please supply your DBS details if you have been through DBS clearing

DBS Number:* / Date of Issue:*

Level of DBS Check:* What level of DBS Clearance do you have?

Enhanced □ Enhanced + Barred List Check □

Adult Safeguarding:What level of Adult Safeguarding have you attained?

None□Level 1□Level 2□Date of Issue:

Emergency ContactDetails:

Name:*
Relationship:*
Address Line 1:*
Address Line 2:
Postcode:*
Contact Number:*

Health Issues of Concern:Do you have any health issues we need to be aware of?

Alzheimer’s / Hearing Impairment
Any progressive Illness / Mental Health Issues
Communications Issues / Mobility Issues
Dementia / Speech Impairment
Epilepsy / Visual Impairment
Are there any other health issues we need to know about?

Skills Offered:Availability:

Skill

/

Day

Admin / □ / Flexible / □
Arts & Crafts / □ / Monday AM / □
Car Lifts / □ / Monday PM / □
Cleaning / □ / Tuesday AM / □
Pet Sitting / □ / Tuesday PM / □
Reading / □ / Wednesday AM / □
Friendship / □ / Wednesday PM / □
Games Playing / □ / Thursday AM / □
Walking / □ / Thursday PM / □
ICT Support / □ / Friday AM / □
Friday PM / □
Saturday AM / □
Saturday PM / □
Sunday AM / □
Sunday PM / □

Are you a member of Age Concern Slough *

Yes: □No: □I would like to know more about Age Concern Membership: □

How did you hear about Give&TakeCare?

Age Concern Slough :□Paper/Magazine: □Talk/Presentation: □ Letter/Newsletter: □

Social Media: □ Word of Mouth: □ Other:

How would you like to receive service updates?*

Email: □Post: □I do not wish to receive any updates: □

How would you like to receive marketing communications?*

Email: □Post: □I do not wish to receive any marketing: □

Would you be willing to participate in any Give&TakeCare surveys?*

Yes: □No: □I do not wish to take part in any surveys: □

How would you like to receive your Give&TakeCare survey?*

Email: □Post: □I do not wish to receive any surveys: □

Statements

The Partner Booklet for CareGivers is a description of the arrangements in relation to your voluntary work for the Associate Charity, as part of the Give&TakeCare Scheme. By enrolling on the Scheme, you acknowledge that you are a volunteer of the Associate Charity and do not become a volunteer of Give&TakeCare.

The Partner Booklet is binding in honour only, is not intended to be a legally binding contract between us, nor between you and the Associate Charity. Neither of us, nor the Associate Charity, nor any CareReceiver, intends any employment relationship to be created either now or at any time in the future as a result of your voluntary work.

I understand the contents of these statements.

Please sign below to show you have read and understand the statements above.

Signed:
Name:
Date:

CareGiver Application Form v1.0Page 1

Give&TakeCareCIC, Heinz Wolff Building, Brunel University London, Uxbridge, UB8 3PH Company Number: 8845839