Macmillan East Kent Volunteer Service

Preferred title: First name: DOB:
Surname/family name:
Address:
Post code:
E mail address:
Tel. (home): Tel. (work or mobile):

References

Please give names, addresses and telephone numbers of two people who can provide professional references for you. If you have been in employment in the last 5 years one must include your last employer. Other professionals could include: social workers, health visitors, day centre staff, tutors, religious leaders or anyone else who has known you in a professional capacity for at least two years. If you cannot provide the names of two referees, please call us on 01227 743703.

Present or previous employer
Name:
Job title:
Organisation:
Address:
Telephone:
E mail address:
How is this referee known to you? / 2nd Referee
Name:
Job title:
Organisation:
Address:
Telephone:
E mail address:
How is this referee known to you?

Rehabilitation of Offenders Act 1974 and Exception Order 1975

Because of the nature of the service for which you are applying, you must provide information about any criminal record. This includes convictions, cautions, reprimands and final warnings. Our power to require this lies in the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 which removes the normal operation of the Act in relation to specific occupations, including the provision of Home Care Services. In the event of being employed in connection with this application, any failure to disclose such convictions could result in dismissal or disciplinary action.

If you have no convictions please write NONE ………………………………………………………...

If you do have any previous or outstanding convictions, cautions, reprimands or final warnings, you will only be asked to supply details of the type of offence, date, sentence, fine etc if you are invited for interview. Please see guidelines on completing the application form for further details.

Declaration

I declare that all the information I have given on this application form is true and accurate, to the best of my knowledge.
Signed: Date:

Please provide details of someone we can contact in the event of an emergency

Emergency Contact
Name:
Address:
Postcode:
Telephone: Mobile:
E mail address:
Relationship to you?

Skills, interests and experience

Please tell us about your skills and training, interests and hobbies and any experience you think are relevant to this application.

Skills & training
Interests & hobbies
Other information

Voluntary Experience

Please provide details of any other volunteering roles you have undertaken

Organisation & Dates / Description of voluntary role

Reason for Volunteering

Please use this section to outline why you would like to volunteer for this service

Please continue on a separate sheet if needed.

Employment Status

Please tick as appropriate. Are you:

In full time paid employmentRetired

In part time paid employmentSemi-retired

UnemployedStudent

Health & Travel

We need to take into account any health issues you may have in order to ensure the best volunteering experience.

Do you have any health problems/conditions of which we should be aware of? Yes / No *

If yes, please provide details ______

______

Are you registered as disabled? Yes / No *

Have you been bereaved in the last year?Yes / No *

Do you hold a valid full driving licence?Yes / No *

*Please circle as appropriate

Availability

Please list the times you would be available to volunteer

Day of week / Morning / Afternoon / Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Please return completed application form in the addressed envelope provided.

If you have any questions, please contact:

Marnie Enever, Volunteer Coordinator, Macmillan East Kent, 16 Reculver Road, Herne Bay CT6 6LE. 08450 958000