Volunteering Application form – pdf version

VOSCUR Reps

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

0203 8860 830 | info@healthwatchhf.co.uk | www.healthwatchhf.co.uk

Healthwatch Hammersmith & Fulham, Martin House, 1 Swift Road, Southall, UB2 4RP

Healthwatch Hammersmith & Fulham is provided by Your Voice in Health & Social Care Company Number: 08397315 Charity Number: 1154672

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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).

Healthwatch Hammersmith & Fulham is provided by Your Voice in Health & Social Care Company Number: 08397315 Charity Number: 1154672

0203 8860 830 | info@healthwatchhf.co.uk | www.healthwatchhf.co.uk

Healthwatch Hammersmith & Fulham, Martin House, 1 Swift Road, Southall, UB2 4RP

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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.

Healthwatch Hammersmith & Fulham is provided by Your Voice in Health & Social Care Company Number: 08397315 Charity Number: 1154672

0203 8860 830 | info@healthwatchhf.co.uk | www.healthwatchhf.co.uk

Healthwatch Hammersmith & Fulham, Martin House, 1 Swift Road, Southall, UB2 4RP

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0203 8860 830 | info@healthwatchhf.co.uk | www.healthwatchhf.co.uk

Healthwatch Hammersmith & Fulham is provided by Your Voice in Health & Social Care Company Number: 08397315 Charity Number: 1154672

Healthwatch Hammersmith & Fulham, Martin House, 1 Swift Road, Southall, UB2 4RP

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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:

0203 8860 830 | info@healthwatchhf.co.uk | www.healthwatchhf.co.uk

Healthwatch Hammersmith & Fulham, Martin House, 1 Swift Road, Southall, UB2 4RP

Healthwatch Hammersmith & Fulham is provided by Your Voice in Health & Social Care Company Number: 08397315 Charity Number: 1154672

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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:

Healthwatch Hammersmith & Fulham is provided by Your Voice in Health & Social Care Company Number: 08397315 Charity Number: 1154672

0203 8860 830 | info@healthwatchhf.co.uk | www.healthwatchhf.co.uk

Healthwatch Hammersmith & Fulham, Martin House, 1 Swift Road, Southall, UB2 4RP

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

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

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):

Single Married Divorced

Are you (Please circle or mark an X)

Employed
Self Employed
Not in paid employment

Co-habiting
A Civil Partner Widowed

Retired
Other (Please specify)

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

Christian (including all denominations) Buddhist
Hindu

Jewish

Sikh Muslim

Any other religion

None
Prefer not to say

0203 8860 830 | info@healthwatchhf.co.uk | www.healthwatchhf.co.uk

Healthwatch Hammersmith & Fulham, Martin House, 1 Swift Road, Southall, UB2 4RP

Healthwatch Hammersmith & Fulham is provided by Your Voice in Health & Social Care Company Number: 08397315 Charity Number: 1154672

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

Heterosexual Gay woman Gay man

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

Bisexual
Other
Prefer not to say

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.

Healthwatch Hammersmith & Fulham is provided by Your Voice in Health & Social Care Company Number: 08397315 Charity Number: 1154672

0203 8860 830 | info@healthwatchhf.co.uk | www.healthwatchhf.co.uk

Healthwatch Hammersmith & Fulham, Martin House, 1 Swift Road, Southall, UB2 4RP

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