Volunteer Application Form

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 Waltham Forest Volunteer

Please state which role you are applying for

Why do you want to volunteer at Healthwatch Waltham Forest?

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:

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 Waltham Forest which may be considered a potential conflict of interest in relation to the role and responsibilities of Healthwatch Waltham Forest:

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information could result in my application being rejected or my volunteer opportunity, should I be successful, being withdrawn.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

Referee 1

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

Surname

Forename(s)

Home Address & Postcode

Telephone Number (Home/Mobile)

Relationship to applicant

Occupation

Email Address

Referee 2

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

Surname

Forename(s)

Home Address & Postcode

Telephone Number (Home/Mobile)

Relationship to applicant

Occupation

Email Address

Equality Monitoring Form

Healthwatch Waltham Forest 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 (dd/mm/yyyy)

Gender

Place and Country of birth

Nationality

Do you live in the borough of Waltham Forest?

If yes, how long have you lived in the borough

Do you use health or adult social care services in Waltham Forest?

Do you consider yourself to have a disability?

What is your religion or belief?

What is your ethnicity?

Data protection statement

The personal data collected will be used for Healthwatch Waltham Forest to record and store contact information for each of our volunteers. This is so we can contact you using the details provided, about your volunteer role. This information consists of both contact and personal details and will be processed by or Healthwatch Waltham Forest staff. All information collected will be entered onto our secure, password protected, cloud based database. A paper copy will also be kept for our records, which will be securely stored by the Volunteer Coordinator. Personal data will be kept for three years after the conclusion of volunteer involvement. The information collected will not be given to other external organisations. By consenting to this privacy notice, you are giving Healthwatch Waltham Forest permission to process your personal data specifically for the purposes identified. You may withdraw your consent at any time by contacting the Volunteer Coordinator at Healthwatch Waltham Forest.

I have read and accepted the privacy notice. I confirm that to the best of my knowledge, the information given on this application is true and correct.

Yes