Volunteer Application Form Volunteer Application Personal InformationTitleSurnameFirst NameAddress and postcodeTelephone Number (Home/Mobile)Email AddressQualificationsPlease list any qualifications you feel are relevant to the role you are applying for: (Please note: There are no essential qualifications for Healthwatch volunteers, having lower qualification levels will not disadvantage you).Role applying forPlease state which Healthwatch Hammersmith & Fulham Volunteer role you are applying forWhy do you want to become a Healthwatch Hammersmith & Fulham Volunteer? Give your reasons:Please outline your experience (work, voluntary or other personal/professional experience) and explain how this makes you suitable for the volunteer role you are applying for. Please refer to the role description. Also include any experience working with or representing “hard to reach” or marginalised groups or individuals:Which languages can you speak?Many of our roles involve communicating with our residents, some of whom may not speak English. Any additional languages you speak will help us reach more people. Please highlight these here.Please give any details of your spare time and recreational interests and activities, or provide any other information you think is missing elsewhere in the application:DeclarationPlease declare any other interests or roles e.g. Councillor of Hammersmith & Fulham which may be considered a potential conflict of interest in relation to the role and responsibilities of Healthwatch Hammersmith & Fulham:I have read the role description and volunteer information. If appointed, I will abide by the requirements for good conduct and practice. I will carry out a fair and reasonable amount of volunteer activity on behalf of Healthwatch Hammersmith & Fulham. This includes completing any training that may be necessary to help me perform in my role as a volunteer. I declare that the information I have provided is honest, full and accurate and I understand that any failure to declare relevant information or the provision of false information could result in my application being rejected or my volunteer opportunity, should I be successful, being withdrawn. I understand all volunteer appointments will be subject to a satisfactory DBS check if required.* I confirm that all the Information provided above is true ReferencesPlease give details of two referees who have known you for at least three years. A referee can be a previous employer or could be someone from an organisation you have volunteered with. They could also be a social worker, probation officer, or anyone else who has worked with you and knows you. They may be contacted at a later date about providing a more in-depth reference.TitleNameAddress and postcodeTelephone Number (Home/Mobile)Email AddressRelationship to applicantOccupationTitleNameAddress and postcodeTelephone Number (Home/Mobile)Email AddressRelationship to applicantOccupationEquality Monitoring FormHealthwatch Hammersmith & Fulham is committed to reaching out to all sections of the community. In order to ensure we are doing this, please complete the form below. The information you give us will remain confidential and used for monitoring purposes only. (This will be detached from your application form and will not be used in the recruitment process).Date of birthGenderCountry of birthPlease selectAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweNationalityDo you live in the borough of Hammersmith & Fulham?Please selectYesNoDo you use health or adult care social services in Hammersmith & Fulham?Please selectYesNoDo you consider yourself to have a disability? (Yes/No):Please selectYesNoPrefer not to sayWhat is your religion or beliefPlease selectChristianBuddhistHinduJewishSikhMuslimAny other religionNonePrefer not to sayWhat is your ethnicity?Please selectWhite - English / Welsh / Scottish / Northern Irish / BritishWhite - IrishWhite - Gypsy or Irish TravellerWhite - Any other White backgroundMixed / multiple - White and Black CaribbeanMixed / multiple - White and Black AfricanMixed / multiple - White and AsianMixed / multiple - Any other mixed / mulitple backgroundAsian / Asian British - IndianAsian / Asian British - PakistaniAsian / Asian British - BangladeshiAsian / Asian British - ChineseAsian / Asian British - Any other Asian backgroundBlack / African / Caribbean / Black British - CaribbeanBlack / African / Caribbean / Black British - AfricanBlack / African / Caribbean / Black British - Any other Black/ African/ Caribbean backgroundOther Ethnic Group - ArabOther Ethnic Group - Any other ethnic groupPrefer not to sayThank you for completing the volunteer application form