PRIVATE AND CONFIDENTIAL
Placement application form
Your detailsName: / Emergency contact name:
Telephone: / Emergency contact telephone:
Address: / Emergency contact relationship:
Emergency contact address:
Postcode: / Emergency contact postcode:
Email address: / Emergency contact email address:
Gender: Male Female / Has this person agreed to be your emergency contact? Yes No
If for any reason you prefer not to give emergency contact details, please sign below:
Signed:
Do you have any health needs that you want to share with us so that we can better support you?
Yes No
For example, you might have panic attacks – and need us to know how best to help. Please specify: / Do you have any access needs?
Yes No
e.g. for a wheelchair or large print for reading?We will use this information to asses which volunteer environments are most suitable for you.
Please specify:
Do you have a driving licence?
Yes No
Do you have any unspent convictions, cautions, reprimands or warnings which as defined by the Rehabilitation of Offenders’ Act 1974?
Yes No
If you answered Yes, please provide more details of your conviction in a sealed envelope. Applications are reviewed individually and, please note, having a criminal conviction will not necessarily prevent you from volunteering with AUKC
Placement role
Volunteer Work Experience Internship
Role applied for (if appropriate) or roles that interest you: / Are you referred by an agency/school/college?
Yes No
Please specify:
Please tell us about your previous education, volunteering and/or work experience completing the following tables in date order (current/most recent first).
Education
Date / School/College/University / Qualification
From / To
Work & Volunteering
Date / Organisation / Role
From / To
Personal Statement
Can you tell us a bit about you including information on yourexperiences, background, skills, interests and what you are hoping to gainby volunteering with us?
Your age: / Under 16* 16-20 21-30 31-50 51-60 61-70 Over 70
*AUKC does not offer placement roles for people under the age of 16 unless they are supported by the Duke of Edinburgh scheme or referred by a local school
Your availability / Monday AM PM / Tuesday AM PM / Wednesday AM PM
Thursday AM PM / Friday AM PM / SaturdayAM PM / Sunday AM PM
References
Name and contact details of two referees, preferably from previous employers but if not, at least one from a previous employer or professional person who knows you well (e.g. Tutor, Solicitor, Police Officer etc.) and one from someone who has known you for at least 5 years (not family members).
Referee one: / Referee two:
How do you know referee one? / How do you know referee two?
Referee one telephone number: / Referee two telephone number:
Referee one email address: / Referee two email address:
Referee one address: / Referee two address:
Has this person agreed to be contacted by us? Yes No / Has this person agreed to be contacted by us? Yes No
I understand that any volunteer placement role offer with AUKC is subject to appropriate references and that AUKC has a comprehensive set of policies and values that reflect the AUKC approach and that of our volunteers.[1]
From time to time we will send you updates and information about volunteer placement at AUKC. Please tick if you agree that we may also send you other updates and information. Email Post Neither
I confirm that to the best of my knowledge, the information given on this form is true and correct.
Signature Date
We are extremely grateful for your interest in volunteering with Age UK Croydon and
look forward to hearing about your experience with us.
Please return this document to or post it to: Private and Confidential,
Volunteer and Student Placement Coordinator,
Age UK Croydon
2 Katharine Street, Croydon, CR0 1NX
[1]Data Protection The data provided on this form will be used by Age UK Croydon for the purposes of supporting our volunteers – and administering, evaluating and monitoring the quality of our volunteer management. We shall use the information you have supplied to us in line with Data Protection Guidelines. We will not contact you about our products, services and the vital work we do for older people if you have not indicated that we may do so (above). Information held by Age UK Croydon is strictly confidential and we do not pass on any personal data about you to organisations and / or individuals without your consent. Age UK Croydon is a registered charity (1081013) and company limited by guarantee. Registered in England and Wales number 3921436. Registered office: 81 Brigstock Road, Thornton Heath, Surrey CR7 7JH.
If you have any comments or questions please use the volunteer enquiry line: 020 3701 3264 or contact