Volunteer Application Form
/Contact and personal information
Title / Date of birth:Name (include middle name if applicable)
Address / Postcode
Home Phone
Mobile/Work Phone
E-Mail Address
Twitter handle
Prefer to be contacted by: / Phone/Mobile/Work/E-Mail/Post (please delete as appropriate)
How did you hear about us
Volunteering with us
What volunteering roles are you interested in?
Befriending - classicBefriending – dementia (specific training provided)
Driving
Telephone befriending (using free minutes on your mobile or landline)
Light gardening
Shopping with a service user
Helping at a social group/s
IT support for an older person (for a limited amount of time)
Odd jobs (e.g. putting up curtains or a shelf)
Office help
Fundraising and events
Other (please state other ways you could offer your time for us, eg design, website, photography etc): ______
Please tell us about why you would like to become a volunteer. Is there anything you hope to gain from volunteering and what has motivated you to contact us:
Work experience
What work (paid or voluntary) do you currently do,or have you done in the past?
What are your interests or hobbies?
Sports watching / Reading / Theatre/films / TVArts and crafts / Gardening / Current affairs / Travel
Music / Keeping fit / Board/card games / Cooking/eating
Dance / Other please state
Do you speak any other languages, apart from English? Please state what they are:
Availability
When are you available for volunteering?
Weekday mornings / Weekend mornings / Please state specific times you are or are not availableWeekday afternoons / Weekend afternoons
Weekday evenings / Weekend evenings
Health
Please tell us if you have any health issues that are relevant to volunteering with us:
Driving
Do you drive and would you be using your car for your volunteering travel?
Yes NoWould you be willing to use your car to give lifts to older people? Yes No
ReferencesPlease give details of two people who have known you well for at least two years, not a relative or partner. Make at least one of the referees a formal contact (employer, previous volunteer org). Let them know that we will be contacting them.
Name 1 / How long have you known this person?Email / Tel
Address
Name 2 / How long have you known this person?
Email / Tel
Address
Person to notify in case of emergency
Name:Telephone number(s)
Relationship to you:
Agreement and signature
REHABILITATION OF OFFENDERS ACT 1974Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975
Because volunteers are placed with vulnerable service users, Link Age Southwarkhas a responsibility to ensure the safety of both users and volunteers.
Regardless of whether convictions are spent or their nature, do you have any convictions that you are required to disclose?
Yes No
If Yes, please supply details on a separate sheet (a conviction will not necessarily exclude you from volunteering with us)
Data Protection:
All information you give us is kept on your personal file and/or stored on our computer database. We use this information to contact you, to send you information about our activities, and to help us plan and keep records of your volunteering. Any information we keep about you is strictly confidential to Link Age Southwark, and will be stored and processed in line with the Data Protection Act 1998.
Declaration:I confirm that, to the best of my knowledge, the information given on this form is accurate.I will inform Link Age Southwark if I am cautioned or convicted after the date of this declaration. I understand that should any statement be found to be false, I may be asked to leave the organisation.I agree to this information being stored and used by Link Age Southwark in line with the Data Protection Act 1998.
Signature: ______Date:______
Please return the completed application form and attached monitoring form to: Link Age Southwark, Dulwich Community Hospital, EastDulwich Grove, London SE22 8PT E-mail: Tel. 0208 299 2623 PTO
Volunteer Monitoring Form
This form is optional, but we would be grateful if you could complete it. Any information you give will be used only for our overall statistics as part of our equal opportunities and diversity policies monitoring.
The information we gather from these forms gives us an overview of our volunteers, by gender, age, ethnicity, and disability. This gives us an idea of how successful we are in promoting equal opportunities in volunteering.
Gender Male Female Other Prefer not disclose
Age Under 16 16-17 inclusive 18-25
26-39 40-59 60+
Ethnicity: Please highlight and tick the box which best fits how you describe yourself.
White
/British
/Irish
/Any other White background
Mixed
/White and BlackCaribbean
/White and BlackAfrican
/White and Asian
Any other Mixed background
Asian or Asian British
/Indian
/Pakistani
/Bangladeshi
Any other Asian background
Black or Black British
/Caribbean
/African
/Any other Black background
Chinese
/Any other ethnic group
Disability: Are you registered disabled? Yes No
Do you consider yourself to be disabled? Yes No