Volunteer Application

Do you understand the commitment as a volunteer and are willing to dedicate some of your free time to Age UK West Cumbria regularly? Yes

Please select the days you will be available to dedicate your time. Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Your personal and contact details.

Select Title

First Name *

Surname *

Date of Birth *

Contact Number

Email Address *

Your home address details.

Street Address *

Town *

County *

Postcode *

Further information about you and why you would like to volunteer.

How did you hear about Age UK West Cumbria? *

Please give details of any past employment, skills or interests you have, or any previous volunteering experience and why you wish to volunteer. *

Which role would you like to volunteer in?

Monitoring information is confidential and used for statistical purposes only, to ensure we are creating equal opportunities.

Gender Identity Male Female Other

Please specify *

Do you consider yourself to have a disability? No Yes

Please give us detail of your disability. *

Employment Status Employed full time Employed part time Self-employed Student Houseperson Unable to work Unemployed Retired

Reason(s) you are unable to work. *

Ethnic Origin Bangladeshi Black African Black Caribbean Chinese Indian Other Asian Other Black Other White Pakistani White British (English) White British (Scottish) White British (Welsh) White Irish Dual Heritage Any other background

Please specify your ethnic origin *

Age Range 16-25 26-35 36-45 46-55 65+

Have you any convictions (including spent convictions under the Rehabilitation of Offenders Act 1974)? No Yes

Please give us full details of your conviction(s), and give dates where possible. *

Volunteer applicant's emergency contact details.

Emergency Contact First Name *

Emergency Contact Surname *

Emergency Contact Relationship to You *

Emergency Contact Home Address *

Emergency Contact Number

Emergency Contact Secondary Number

Do you have any medical conditions we need to be aware of, or that might affect your volunteer work? No Yes

Please give us details of your medical condition. Please note, your volunteer manager will discuss this with you before you begin volunteering. *

Please provide 2 references. You may provide these during your induction if you need time to prepare.

Are you able to provide 2 referees now? (They must not be relatives or your partner(s)) Yes No

Referee 1

Provide your first referee's details.

Full Name *

Home Address *

Contact Number

Email Address *

In what capacity do they know you? *

Referee 2

Provide your second referee's details.

Full Name *

Home Address *

Contact Number

Email Address *

In what capacity do they know you? *

Read and accept the terms and conditions of the Confidential Code of Practice. Please be aware, you will be required to sign this sheet in person with your signature during your volunteering induction.

Confidentiality code of practice The following notes on confidentiality are issued to all staff and volunteers of Age UK West Cumbria. 1. All information concerning users is CONFIDENTIAL 2. Information must NOT be disclosed to anyone other than in the following circumstances:- 2.1. with the users and/or referrer’s consent 2.2. to work with others in the service (voluntary or paid), to the extent needed to enable them to carry out their work. 2.3. to others involved in care work with the client, to the extent needed to enable them to carry out their work. Examples are Health Workers, Social Workers, other Voluntary Organisations. 2.4. in exceptional circumstances when the need to protect the health and welfare of the user or another person overrides the user’s right to confidentiality. Under these circumstances the Chief Executive or Service Manager only may authorise the disclosure. 2.5. when disclosure is required by law. 3. Information supplied by a Doctor or another Health Worker should not be disclosed to the user without the professional’s consent. 4. whenever you are not sure whether information should be disclosed, you must consult your line manager. I confirm that I understand and agree to abide by the Confidentiality Code of Practice and Policy statement. Yes

I declare that the information given on this form is to the best of my knowledge and belief true and complete. Yes

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All volunteers with Age UK West Cumbria can expect: