Volunteering ApplicationForm

Title: FFirst Name: Surname:

Address:

Town: Postcode:

Phone Number: Mobile Number:


e-mail address:

Other languages spoken: (please list)


Areas of interest (you may tick as many as you like)

AdminLearning Disabilities Training

Advocacy Community Care Event planning

Mental HealthBefriending Facilitating

Older peoplePhysical/sensory impairment IT

Others (please specify):

Activities which you are willing to undertake: (you may tick as many as you like)

Arts & CraftsGroup WorkPromotional Events

Running Coffee MorningsClient VisitsPromotional work

MeetingsReport Writing

Others (please specify):

Your availability: (you may tick as many as you like)

Monday Tuesday Wednesday Thursday Friday

am pm am pm am pm am pm am pm

Evenings and weekends when required with notice? Yes No

Approximate number of hours available to Volunteer:

Preferred location of work(you may tick as many as you like):

KirkleesNorth YorkshireDoncaster

LeedsYorkRotherham

CalderdaleTamesideHull & East Riding

SheffieldScunthorpeWakefield

BarnsleyGrimsbyOthers

Why do you want to become a volunteer and what can you bring to Cloverleaf Advocacy?

Please state current and previous voluntary work and/or relevant life experience. Please continue on a separate sheet, if required, marked with your name.

Do you have any significant health problems which are likely to affect your capacity to fulfil the volunteering role? If yes please give details below.

Convictions

This post is exempt from the provisions of section 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation of Offenders Act 1974 (Exemptions) order 1975. You are asked to declare any convictions. This includes offences which would otherwise be spent under the provisions of the above act. The successful candidate will be required to agree to a police record check. Failure to disclose any convictions which are subsequently stated in a Police Records check may result in dismissal.

Please complete one of the two statements below.

  1. I confirm that I have no convictions at or from a court and no pending prosecutions.

(Please sign)………………………………………………

  1. Please list below details of convictions:

Date / Offence / Court / Sentence

Signed

Do you have a driving licence: Yes No


Do you have access to a vehicle: Yes No

Where did you hear about the volunteering role? (please state)

FURTHER INFORMATION

References:

Please give the name and address of two people who can comment on your abilities to fulfil this role but are not related to you. This may be your most recent employer, an education professional etc.

Referee 1

/

Referee 2

Name:

/

Name:

Address:

/

Address:

Postcode:

/

Postcode:

Tel:

/

Tel:

Relationship to applicant:

/

Relationship to applicant:

References will only be checked if volunteers are accepted through an interview process. (Please note any offer of any volunteering opportunity will be made subject to satisfactory references.)

Declaration:

I confirm that to the best of my knowledge the information given on this form is true and correct.

Signed Date

EQUAL OPPORTUNITIES FORM – PRIVATE AND CONFIDENTIAL

The information provided is to enable us to monitor the effectiveness of the equal opportunities policy and for no other reason. All applicants are asked to fill in the information below. This will be used solely for monitoring purposes and will be treated in the strictest confidence.