Diversion and Resettlement Service

Volunteer Application Form

Name: ______

Address:______

______

Postcode: ______Date of Birth: ______

Telephone Number(s) ______

Email Address: ______

Qualifications: ______

Work Record Summary: ______

______

Please answer the following questions / Mind Comments
  1. Why have you applied to volunteer with Mind?
Do
  1. What experience (if any) do you have of working within the criminal justice system?

  1. What experience (if any) do you have of working with people with mental health issues or other vulnerabilities?

  1. How would you feel about supporting offenders with specific offences, such as rape, murder or child abuse?

  1. What steps would you take to ensure the safety of yourself, other staff and clients when providing this service?

  1. TheDiversion and Resettlement Service is demand led and volunteers may be called upon at anytime of the day often for an unspecified period of time - what would your availability be?

  1. Transport
Have you got access to a car? Yes / No
Approximately how long would it take you to get to the Mind Centre, Teesside Magistrates court or Middlehaven Police Station?
  1. Do you have any health issues or needs that we can help with to enable you to volunteer with us?

  1. Is there any further information you wish to add?

References - we require 2 references who have known you for 12 months or more. They can be friends, work colleagues, college tutors but not relatives.

Reference one: Name:______

Job Title (if applicable): ______

Address: ______

______Postcode: ______

Telephone Number(s): ______

Email Address: ______

Reference two: Name:______

Job Title (if applicable): ______

Address: ______

______Postcode: ______

Telephone Number(s): ______

Email Address: ______

Volunteer Signature: ______Date: ______

Interviewer Signature: ______Date:______

(Mind)

Equal Opportunities Monitoring

Middlesbrough and Stockton Mind is committed to developing positive policies to promote equal opportunities throughout the organisation. To assist us in monitoring the effectiveness of this policy in all our services, we are grateful if you would complete the form below.

Name

Age - what is your age range? 16-24 25-34 35-44 45-54 55-64 65+

Disability – do you consider yourself to have a disability? Yes No
If you have answered yes, please indicate the type of impairment which applies to you by ticking the appropriate box(es) below:

Physical impairment Sensory impairment Mental health condition

Learning disability Long standing illness or health condition

Other Prefer not to say
This information is for monitoring purposes only. If you need ‘reasonable adjustment’, please inform Mind so the reasonable steps can be taken to meet your particular needs.

Gender – how would you describe yourself? Male Female Prefer not to say
Gender re-assignment – do you live or want to live, full time in the gender opposite to that which you were assigned at birth?

Yes No Prefer not to say
Sexual orientation – how would you describe yourself?

Bisexual Gay man Gay woman/Lesbian

Heterosexual/Straight Other Prefer not to say
Religion or belief – which group do you most identify with?

No religion Christian Buddhist

Hindu Jewish Muslim

Sikh Any other religion Prefer not to say
Ethnic group or background – how would you best describe yourself? (based on the Census 2012 categories)
A White

English/Welsh/Scottish/Northern Irish/British Irish

Gypsy or Irish Traveller Any other White Background
B Mixed/Multiple Ethnic Groups

White and Black Caribbean White and Black African

White and Asian Any other Mixed/Multiple Ethnic
Background
C Asian/Asian British

Indian Pakistani

Bangladeshi Chinese

Any other Asian Background
D Black/African/Caribbean/Black British

African Caribbean

Any other Black/African/Caribbean Background
E Other Ethnic Group

Arab Any other Ethnic Group
Relationship status – how would you describe yourself?

Single Married/Civil Partnership Divorced/Dissolved Civil
Partnership

Widow/Widower Co-habiting Prefer not to say
Caring responsibility – please tick all that apply:

I am not responsible for caring for anyone I care for a child/children

I care for another relative I care for someone else
Employment status – please tick all that apply:

Employed – full-time Employed – part-time Employed – sessional Retired

Self-employed Unemployed Volunteer

Student/In training Primary carer Sick/Incapacity

Thank you for completing this monitoring form.

The information that you provide is completely confidential and will only be used to ensure that services and opportunities within Middlesbrough and Stockton Mind are equally available and to monitor the effectiveness of our equality and diversity policy.