Volunteering Application . doc form

Healthwatch Hammersmith & Fulham Volunteer Application Form

This application form should be completed by referring to the role description and other information provided.

Please type your answers to the questions into the text boxes. These will expand as you type until they fill the box. If you feel a question does not apply, mark it N/A (not applicable).

Please email forms to info@healthwatchhf.co.uk  . Once submitted, your application will be considered by an appointment panel. We will then interview those people who best meet the role description. Unsuccessful applicants may be invited to participate in other ways.

If you want to apply to be a Healthwatch Hammersmith & Fulham volunteer, but for any reason feel that a written application form is not suitable for you, please call us on 0203 8860 830 or email info@healthwatchhf.co.uk

All information provided in this application form will be treated as confidential, used only for the purposes of selection of Healthwatch Hammersmith & Fulham volunteers, and will be seen only by those directly involved in the appointment process. 

If you have any questions about filling in this application form, or require any further information about the application procedure, or Healthwatch Hammersmith & Fulham, please call us on 0203 8860 830 or email info@healthwatchhf.co.uk

Personal Information

Title (Mr/Mrs/Miss/Ms/Dr/Other):  
Surname:

Forename(s):

Previous Surname(s) (if any):

Home Address & 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).
















Reasons for applying and suitability for becoming a Healthwatch Hammersmith & Fulham Volunteer

Please state which Healthwatch Hammersmith & Fulham Hammersmith & Fulham 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 (refer to the role description). Also include any experience working with or representing “hard to reach” or marginalised groups or individuals:





















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:




















For handwritten applications please continue to the box below if required.

































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:




Please sign below (writing your name in the box constitutes a signature) to indicate that you wish to apply.

Declaration

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.

Signature: 




Date: 



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.

Referee 1

Title (Mr/Mrs/Miss/Ms/Dr/Other):  
Name:

Address & Postcode:




Telephone Number  (Home/Mobile): 

Relationship to applicant: 

Occupation: 

Email Address: 

Referee 2

Title (Mr/Mrs/Miss/Ms/Dr/Other):  
Name:

Address & Postcode:


Telephone Number  (Home/Mobile): 

Relationship to applicant: 

Occupation: 

Email Address: 

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 (Male/Female): 
Place and country of birth:
Nationality: 
Do you live in the borough of Hammersmith & Fulham? (Yes/No) If yes, how long have you lived here for: 



Do you use health or adult care social services in Hammersmith & Fulham? (Yes/No): 



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


What is your relationship status? (Please circle or mark an X) 

Single Co-habiting 
MarriedA Civil Partner
Divorced Widowed

Are you (Please circle or mark an X) 

Employed Retired  
Self EmployedOther (Please specify) 
Not in paid employment

What is your religion or belief? (Please circle or mark an X) 

Christian (including all denominations) Jewish Any other religion
Buddhist SikhNone
HinduMuslimPrefer not to say 

What is your sexual orientation? (Please circle or mark an X)

HeterosexualBisexual 
Gay woman Other
Gay manPrefer not to say 

What is your ethnicity? (Please circle or mark an X)


White:  English  Welsh  Scottish  Northern Irish  Irish Gypsy or Irish Traveller Polish  Other White

Mixed: White and Black Caribbean White and Black African White and Asian  Other Mixed background

Asian/Asian British:  Indian  Pakistan  Bangladeshi Chinese Other Asian 

Other Ethnic Group: Arab Any other ethnic group

Black/African/Caribbean/Black British:  African  Caribbean Black, Black Scottish or Black British  Other Black/African/Caribbean

Prefer not to say 

Thank you for completing the volunteer application form.