Volunteer Application Form - Healthwatch Hammersmith & Fulham

Personal Information

Title

Surname

First Name

Address and postcode

Telephone Number (Home/Mobile)

Email Address

Qualifications

Please 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 for

Please state which Healthwatch Hammersmith & Fulham Volunteer role you are applying for

Why 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:

Declaration

Please 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information could result in my application being rejected or my volunteer opportunity, should I be successful, being withdrawn.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

References

Please 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.

Title

Name

Address and postcode

Telephone Number (Home/Mobile)

Email Address

Relationship to applicant

Occupation

Title

Name

Address and postcode

Telephone Number (Home/Mobile)

Email Address

Relationship to applicant

Occupation

Equality Monitoring Form

Healthwatch 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 birth

Gender

Country of birth

Nationality

Do you live in the borough of Hammersmith & Fulham?

Do you use health or adult care social services in Hammersmith & Fulham?

Do you consider yourself to have a disability? (Yes/No):

What is your religion or belief

What is your ethnicity?