Your Details
Title (Ms/Mr/Dr etc) *:
First Name *:
Surname *:
Address Line 1 *:
Address Line 2:
Town *:
Postcode *:
Telephone *:
Mobile *:
Email Address *:
Date of Birth *:
Gender *: Male Female Transgender Other
Ethnicity (e.g White British) *:
Do you consider yourself to have a disability? *: Yes No
If "Yes" please give more details:
Blue Badge Holder: Yes No
Religion or Belief *: No Religion Faith
Relationship Status *: Single Married Civil Partnership Cohabiting Widowed Divorced Other
Sexuality *: Heterosexual Lesbian Gay Bisexual Other
Employment Status *: Retired Employed Unemployed Other
Present employment or voluntary work:
(Please provide details of current employment or volunteer work e.g. job title, name of organisation and dates employed/volunteered if applicable)
Please state which voluntary role(s) you are you interested in? *: Transport Driver Home Support/Group Support Fundraising
Transport
Do you have use of a car for voluntary work? *: Yes No
Do you have a current, clean driving licence? *: Yes No
Availability
Afternoons Mon Tue Wed Thu Fri
Application
Please indicate any personal experience of cancer or other life limiting illness?
Have you had a major personal loss within the last 2 years?
(e.g. Redundancy, bereavement, divorce, major illness etc)
Please indicate why are you interested in helping people with cancer or other life-limiting illness?
Please provide information of any qualifications, recent training and/or experience that is relevant to volunteering with Being There
Please provide information of any hobbies and interests
Your Referees
Because of the confidential nature of the work it will be necessary for us to take up references. Please give details of two people (NOT RELATIVES) who have known you for at least two years, preferably in connection with some work (either paid or voluntary) to whom we may apply for references. Submitting this form will be treated as consent to these enquiries being made.
Reference 1
Forename:
Surname:
Address Line 1:
Address Line 2:
Town:
Postcode:
Telephone:
Mobile:
Email Address:
Job Title (if applicable):
Company (if applicable):
Reference 2
Forename:
Surname:
Address Line 1:
Address Line 2:
Town:
Postcode:
Telephone:
Mobile:
Email Address:
Job Title (if applicable):
Company (if applicable):
Emergency Contact Details
Full Name *:
Telephone *:
Mobile *:
Email Address *:
Relationship to you *:
Declaration
I confirm that the information on this form is true and correct
I agree to abide by the volunteer policies/procedures of Being There
In accordance with the Data Protection Act 1998 I give permission for this personal information to be stored and processed for the purposes of volunteering and monitoring and for sensitive data to be stored and processed in connection with equal opportunities, health and safety reasons and compliance with the requirements of national standards.
Declaration of Criminal Record
As an organisation committed to equality and diversity, Being There recognise the contribution that all people can make as volunteers and so we welcome enquiries of interest from everyone. We recognise too that some potential volunteers have criminal records and are reluctant to apply for voluntary work where this would involve the disclosure of their record. We understand that people are often may fear they will not be treated fairly because of them.
Please rest assured that we will handle any information provided below in confidence. Should you disclose them, we will not take into account convictions deemed spent under the Rehabilitation of Offenders Act, unless the voluntary position is exempt from the Act.
Some of our volunteer positions are exempt from the Rehabilitation of Offenders Act. As such, we will ask for disclosure of both spent and unspent convictions, and also cautions, reprimands, and final warnings. Where appropriate to the role, we will also ask you to agree to a Disclosure and Barring Service check. If the DBS check reveals information that we were not previously aware of, we will discuss the matter with you before making a final decision. Whilst it is unlikely that a Criminal Record would prevent you from volunteering, we consider each case on an individual basis.
Have you ever been convicted by the courts or cautioned, reprimanded or given a final warning by the police? * Yes No
If yes, please give details of offences, penalties and dates:
Are you aware of any police enquires undertaken following allegations made against you, which may have a bearing on your suitability for this post? * Yes No
If yes, please give details:
* indicates required field
