Please complete this form in BLOCK CAPITALS using INK or a BALL POINT PEN. Please complete this form in BLOCK CAPITALS.

SECTION 1: VOLUNTEER WAIVER AND RELEASE STATEMENT FOR RESIDENTS OF NORTHERN IRELAND.

It is important that you read and accept the following before proceeding.

It is our goal to make your volunteer experience as enjoyable as possible. Special Olympics Ireland Limited requires all volunteers to agree to the following waiver.

I understand that:

  • The information that I provide may be verified and I give permission to Special Olympics Ireland Limited (hereafter referred to as SO Irl) to make enquiries of nominated referees to determine my suitability to act as a volunteer.
  • In the course of volunteering for SO Irl I may be dealing with confidential information and I agree to keep such information in the strictest of confidence.
  • SO Irl has a Code of Ethics & Good Practice Policy that provides an environment that promotes the safety of each individual at all times. (Once a volunteer is “officially” registered they will be provided with a copy of Special Olympics Ireland Code of Ethics & Good Practice Volunteer Guide). I agree to make it my duty to become familiar with and abide by this Code at all times.
  • The relationship between SO Irl and the volunteer is an “at will” arrangement and either the volunteer or SO Irl may terminate it at any time without cause or notice.
  • I understand that SO Irl operates on a charitable and not for profit basis and that, as such, it does not accept responsibility for personal injury, illness, death or loss or damage to the property of volunteers however arising (except as a direct result of the negligence of SO Irl or its employees) and I hereby waive any such claims against SO Irl, its employees, volunteers or agents.
  • I understand that my personal information will be held and processed by SO Irl in accordance with the Data Protection Act 1988, as amended by the Data Protection Act 2003 and I fully consent to same.
  • I understand that the nature of SO Irl and the participating athletes make it necessary to have a screening process in place for all volunteers and I hereby consent to the use of such a screening process on any application I may submit in this regard.
  • By signing below I authorise a Protection of Children and Vulnerable Adults (POCVA (NI)) Service check to be carried out on me by the Department of Health, Social Services and Public Safety (DHSSPS) and PSNI- (further details in Section 2).
  • I confirm that I have read this Waiver and Release statement, understand it and willingly agree to it. I confirm that all the information I provide is true and complete.

NAME: ______Date of Birth: ______

* SIGNED: ______DATE: ______

If you are between the ages of 15-18 years, the signature of your parent or legal guardian is also required.

SIGNATURE OF PARENT / LEGAL GUARDIAN______DATE: ______

section 2: Information about and consent to the pOCVA (NI) Service check by applicants for posts involving work with children and/or VULNERABLE ADULTS.

It is policy of Special Olympics Ireland to ask for a Protection of Children and Vulnerable Adults (POCVA (NI)) Service check to be carried out by the Department of Health and Social Services and Public Safety (DHSSPS) on all our volunteers, residing in Northern Ireland. The purpose of the check is to make sure that people are not assigned to volunteer roles who might be a risk to children and/or adults with a learning disability.

The check will tell us whether you have a criminal record, or if your name is included in the DHSSPS Disqualification from Working with Children and/or Vulnerable Adults List or included on the Department of Education List 99. Any information which we receive will be treated confidentially, and will be discussed with you before we make a final decision. After the decision has been made the information will be destroyed.

You MUST tell us if you have ever been convicted of a criminal offence, or cautioned by the police, or bound over. You MUST include ALL offences, even minor matters such as motoring offences, and “spent” convictions, that is, events/convictions which happened a long time ago. If you leave any information out it may effect your application.

Do you have any prosecutions pending?YesNo

(If yes, please give details)

______

Have you ever been convicted at a court or cautioned by the police for any offence?YesNo

If yes, please list below details of all convictions, cautions, or bind-over orders. Give as much information as you can, including if possible, the offence, the approximate date of the court hearing and the court which dealt with the matter, the relationship between the offence and the position applied for.

______

______

* Please note that any information supplied in response to the above questions (Section 5) will be treated with total discretion and will not be held on a computer database.

SECTION 3 : PERSONAL INFORMATION
TITLE (Mr, Mrs, Miss, Ms. Etc…)
*FIRST NAME
MIDDLE NAME
*SURNAME
FORMER / MAIDEN NAME
*DATE OF BIRTH
(DD/MM/YYYY) / D / D / M / M / Y / Y / Y / Y
GENDER (Place a tick () in the relevant box.) / MALE FEMALE
NATIONALITY
National Insurance Number
Other
DRIVER’S LICENSE (Place a tick () in the relevant box.) / YES NO
Driver’s License Type / A / B / C / D / E+
Contact Information
TELEPHONE (MOBILE) / ( )
TELEPHONE (DAY) / ( )
TELEPHONE (EVENING) / ( )
EMAIL ADDRESS
CURRENT HOME ADDRESS (Please let us know where it is best to send letters to you)
ADDRESS LINE 1
ADDRESS LINE 2
ADDRESS LINE 3
CITY / TOWNLAND (e.g Ardee, Ballymoney)
COUNTY
POSTCODE
PREVIOUS HOME ADDRESS(Please list all previous addresses within the last 5 years. Details of anywhere else you have lived in the UK or Republic of Ireland apart from N. Ireland, prior to the 5 years, should also be provided)
ADDRESS 1
ADDRESS 2
ADDRESS 3
ADDRESS 4
ADDRESS 5
ANY OTHER ADDRESSES
Please indicate who to contact in case of an emergency.
Emergency Contact name
Relationship to you
TELEPhone (of emergency contact) / ( )
Mobile (of emergency contact) / ( )

Please list two friends or non family referees (each of whom has known you for 2 years or more) who may be contacted by Special Olympics Ireland

FIRST NAME
SURNAME
ADDRESS 1
ADDRESS 2
ADDRESS 3
CITY / TOWNLAND
COUNTY
POSTCODE
Telephone (mOBILE)
TELEPHONE (DAY)
TELEPHONE (EVENING)
RELATIONSHIP TO YOU:
FIRST NAME:
SURNAME
ADDRESS 1
ADDRESS 2
ADDRESS 3
CITY / TOWNLAND
COUNTY
POSTCODE
Telephone (mOBILE)
TELEPHONE (DAY)
TELEPHONE (EVENING)
RELATIONSHIP TO YOU:

SECTION 4: EXPERIENCE & SKILLS

What is your occupation (homemaker, engineer, teacher etc)
Have you volunteered with Special Olympics before? / YES NO
If “Yes”, please provide details.
(eg. 2003SOWSG)
Are you currently involved in Special Olympics Ireland? / YES NO
If “Yes”, please provide name of affiliated group/committee/network etc
What is your role? Eg coach/ secretary
Are you applying in conjunction with, or as a member of a group (e.g. business, school)? / YES NO
If “Yes” please list the name of this organisation or group.
Professional Skills

The following list is indicative of the skills we require. Please indicate, in order of preference, three skills you wish to contribute as a volunteer.

(Please note: the number 1 = first preference, the number 2 = second preference and the number 3 = third preference)

AdministrationSecurityDrivingFundraising

Event ManagementTrainingData EntryTransport Planning

FinanceEntertainmentCateringWebsite Management

Public SpeakingMerchandisingCustomer ServiceComputer Proficiency

Media/PRHuman ResourcesPublicationsLogistics Safety

Medical Skills

Do you have first aid training? YesNo

Do you have medical/ healthcare background? YesNo

If “Yes”, please tick the relevant boxes below.

QualifiedStudentQualifiedStudent

Ambulance DriverDentist

Massage TherapistMedical Practitioner

Medical Records ClerkOptometrist

PhysiotherapistPodiatrist

NurseAudiologist

Sports Skills

List of sports athletes competing in during 2006 Special Olympics Ireland Games

1. Aquatics7. Equestrian

2. Athletics8. Football

3. Badminton9. Golf

4. Basketball10. Gymnastics

5. Bocce11. Pitch & Putt

6. Bowling12. Table Tennis

Motor Activities Training Programme (MATP)

Do you have a background in any of the above Special Olympics Ireland sports?YesNo

If “Yes”, please provide details of up to two sports and your level of involvement.

Name of first sport:

AdministratorCompetitorCoachOfficialCompetition Management

If you are an official or a coach, please let us know the following:

The qualification

The qualifying body

The expiration of the qualification

Name of second sport:

AdministratorCompetitorCoachOfficialCompetition Management

If you are an official or a coach, please let us know the following:

The qualification

The qualifying body

The expiration of the qualification

Other

Is there any other relevant information you wish to supply?

______

PLEASE RETURN THIS APPLICATION FORM TO:

2006 GAMES – BELFAST

VOLUNTEER DEPARTMENT

ULSTER HALL

BEDFORD STREET

BELFAST BT2 7FF

NORTHERN IRELAND

SECTION 5 : PHOTO

In order for you to be registered as a volunteer with Special Olympics Ireland, you will need to provide us with either:

(a)A Digital Image

OR

(b)A COLOUR passport quality photo

Rules to adhere to:

  • The photo/digital image must be of passport quality.
  • The photo/digital image must measure approximately 5cm X 4cm (passport dimensions).
  • The photo/digital image must be from the shoulders of the volunteer up.
  • The background of the photo/digital image must be clear and pale.
  • The volunteer in the photograph should NOT be wearing a hat or sunglasses.
  1. A DIGITAL IMAGE

If you choose this option, please ensure that:

  • The digital image is saved in the format LASTNAME_FIRSTNAME_DATEOFBIRTH.jpeg e.g. RYAN_PAUL_251189.jpeg
  • The image should be approximately 600dpi. .
  • Please email your digital image to with email title to be “2006 Games - Belfast Photo”
  1. A COLOUR PHOTO

If you choose this option, please ensure that you:

  • Attach the photo to the space below using either glue or double sided tape. Staples or tape that covers the photo will render it unusable.
  • Write clearly on the back of this photo AND below your:

FIRSTNAME:

SURNAME:

DATE OF BIRTH (DD/MM/YYYY):

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