Healthwatch Cheshire East Volunteer

Healthwatch Cheshire East Volunteer

Application form

Name
Home Address / Post Code
Telephone / Home / Mobile
Work
E-mail
Please tick which role(s) you are interested in applying for. You can volunteer in more than one area.
Operational Board Member
Sub Group Member (please select which) / Marketing and Communications
Scrutiny
Engagement and Research
Attending Strategic partnership meetings
Why do you want to become a Volunteer for Healthwatch Cheshire East?
Please complete with reference to the aim of the volunteer role.
(box will expand with typing)
Please outline the skills knowledge, experience and approach you would bring to Cheshire East
Please complete with reference to any skills and experiences listed in the role description.
(box will expand with typing)
What particular qualities do you think you could bring to Healthwatch Cheshire East?
(box will expand with typing)

Reference

Please provide a referee. Please note this should not be a family member

Name
Role
Personal Contact Details
Telephone / Home / Mobile
Work
E-mail

Declaration of Eligibility:

I am over 18 years old and live in Cheshire East and / or am a customer of health and social care services provided in Cheshire East.

Signature / Date

Please note:

All Volunteers will be required to sign a Declaration of interest form

All Volunteersmay be required to undertake a DBS Check

Please return this form to: Healthwatch Cheshire East,

1a Gatefield Street, Crewe, CW1 2JP

Email:

All forms must be returned by xxxinformal interviews will take place during early August.

All questions regarding the Healthwatch VolunteerRole should be addressed to:

Tel:03300 882843

Email:

DIVERSITY

We are committed to equality of opportunity for everyone.

To assess whether our policy is effective, we need to monitor it and to do this we need the information requested below. This will also enable us to comply with our obligations under current legislation. The information will not be seen by anyone involved in the interview and selection process.

The information below will be used only for monitoring purposes and not in the selection process. Please tick correct boxes:
Gender: / Male / Female
Marital Status: / Married / Civil Partnership / Single
Age: / 18-25
54-75 / 26-34
Over 75 / 35-44 / 45-54
Please indicate your ethnic origin:
White: / Black or Black British: / Asian:
White British / / Caribbean / Indian
White Irish / / African / Pakistani
White European: / / Other Black: / Bangladeshi
Other White: / / Other Asian
Mixed: / Other:
White and Black Caribbean / Chinese /
White and Black African / Gypsy / Traveller /
White and Asian / / Other /
Other Mixed: /
Do you consider yourself to have a disability? / Yes / No
Source of advertisement:
Newspaper (which) / E-mail circulation
Job Centre (which) / Website (which)
Other (please state)

Healthwatch Cheshire East Volunteer Application FormPage 1 of 4