A Company Limited by Guarantee Registered in England No. 7140691
Registered Charity No 1135423. Registered with the Care Quality Commission. Provider 1-229486170
Koinonia Christian Care 4 Winchester Road Worthing West Sussex BN11 4DJ
Tel: 01903 237764 Email:
Volunteer Application Form
Personal Details
Surname (Mr. Mrs. Miss. Ms) …………………………….…… Christian Names(s)…………………………………..
Address…………………………………………………………………………………………………………………………
……………………………………….Post Code………………….….. Date of Birth ………………………………….
Home Tel. No.…………………………...……..Mobile Tel. No. ……………………………………………
Church attended ……………………………………………Are you in Membership? ………………………………..
Referees
Please provide details of your Pastor or Minister and ne other friend or former employer that we may contact to obtain a reference.
1. Pastor or Minister2. Other Referee
Name…………………………………………….Name…………………………………………………….
Address ……………………………………..……Address ………………………………………………..
………………………………………………………. ……………………………………………………………….
.
Post Code …………………Tel………………….. Post Code …………………Tel…………………………..
What has moved you to become involved in the ministry of Koinonia?
...... ………………………………………………………………………………
What tasks would you like to undertake?
……………………………………………………………………………………………………………………………………
………………………………………………………………………………..
Do you have any special gifts or skills that would be of service or benefit to the residents at Koinonia?
……………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………
2.
How did you hear about Koinonia? ………………………………………………………………………………………..
Have you visited the home or do you know any of the residents past or present? Please give details
…………………………………………………………………………………………………………………………………….
Do you have a vehicle suitable for transporting elderly residents and would you be able and willing to
accompany them to GP or Hospital appointments etc?……………………………………………
Thank you for your interest in Koinonia. Please sign and date your application and return it for my attention.
Signed …………………………………………Date………………………………………
Please note that as we provide care for Vulnerable Adults all successful applicants must complete a DBS (Disclosure and Barring Service) and ISA (Independent Safeguarding Authority) application and receive full clearance before any Voluntary work may commence.
Phyllis Alabaster
Manager.
On behalf of the Management Trustees
Equal Opportunity Recruitment Monitoring FormJob applied for:
In compliance with our Equal Policy, we monitor job applications to make sure discrimination on the grounds of sex, sexual orientation, gender reassignment, race, ethnic origin, religion, marital status, age and disability do not occur. We would be grateful if you would complete and return this form with your job application form. However, please note that providing this information is optional.
Confidential
1. Gender / MaleFemale
2. Ethnic Origin / White British
Black/Black British
Chinese / White Irish
Asian
Mixed / White Other
Asian British
Other:
3. Sexual orientation / Heterosexual Homosexual
4. Marital Status / Married
Divorced / Single
Widowed / Separated
Other:
5. Religious belief / Buddhist
Christian
Hindu / Jewish
Muslim
Sikh / None
Other:
6. Disability / Do you consider yourself to be disabled under the Disability Discrimination Act?
(The Disability Discrimination Act (1995) defines disability as “a physical or mental impairment which has a substantial and adverse effect on a person’s ability to carry out day to day activities”.) / Yes
No
If yes, what is the nature of your disability? (optional)
7. AgeRange / Under 18
36 – 45
65+ / 18 - 25
46 – 55 / 26 - 35
56 - 65
The information you have provided here will stored either on paper records or a computer system in accordance with the Data Protection Act 1998 and will be used solely to monitor the diversity of our policy regarding Equal Opportunity issues.