Registration Form Personal details Title Mr  Mrs  Miss  Ms  Other



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Volunteering Tool 3


Volunteer Registration Form


Personal details




Title Mr  Mrs  Miss  Ms  Other (please specify)      

First name(s)      

Surname      

Email      

Contact address      




Postcode      

Tel Day       Eve       Mobile      

Volunteering with Marie Curie Cancer Care




If you know what role or type of volunteering you would like to do, please give details.

     


Availability




How regularly do you wish to volunteer?  Monthly  Fortnightly  Weekly  More often

When would you be available to volunteer?




AM*

PM*

Evening

Please tick the hours that you are available to volunteer, but note that not all roles are available at all times.

Mon







Tues










Wed










Thur










Fri










Sat







*AM will normally be until 1pm and PM from 1pm

Sun







Additional information




Are you under 18 years old?  Yes  No

If yes, please give your date of birth      



Do you have a current driving licence?  Yes  No

If yes, do you have the use of a car?  Yes  No



Do have the right to volunteer in the UK?  Yes  No  Not sure

If you are here on a visa, there may be restrictions.



Criminal Records Check

For some roles where there will be contact with vulnerable groups (eg patients or children) you may need a criminal records check. If you have any questions about your own situation and would like to discuss this in confidence, or if you would like to request a copy of our Ex-Offenders Policy, please contact us.





About you




What interests, skills and experience could you bring to Marie Curie Cancer Care? Please give examples from your home or work life and include why you would like to volunteer with us.

     


Special requirements




We welcome applications from volunteers with disabilities. Do you have any special requirements/health issues that you would like to tell us about or that may have an impact on the activity that you can do?

     


References




Please give details of two referees. Both should know you well and for a minimum period of six months. Referees should not be family members. We will only contact them if you are accepted as a volunteer.

Referee one

Referee two

Name:      

Name:      

Address:      

Address:      

Telephone:      

Telephone:      

Email:      

Email:      

How do you know this person?

     

How do you know this person?

     

How long have you known them?      

How long have you known them?      

Data protection act




Your personal details will be treated as confidential and kept for no longer than necessary. If you are accepted as a volunteer the information you have provided on this volunteer registration and monitoring information form will become part of your volunteer records which will be used to plan and record your practical involvement as a volunteer.
Would you like to be contacted with information about fundraising events and volunteering activities other than the one you have applied for? If yes please tick if you are happy to be contacted by:

Phone  Post  SMS text  Email 




I am aware that the information I have provided will be treated confidentially and consent to it being used and stored in the capacity stated


Signature       Date      

Volunteer monitoring information


We welcome interest from anyone wishing to volunteer at Marie Curie Cancer Care. We aim to reflect the diversity of the local community in terms of ethnic and cultural background, gender, age and disability. Therefore, Marie Curie Cancer Care asks all potential volunteers to complete the details below. The information will be used for compiling statistics for monitoring purposes and will be treated confidentially.
Please note that the completion of any part of this form is entirely voluntary.




Where did you hear about volunteering with Marie Curie Cancer Care?      




Ethnic Group




Black or Black British

Asian or Asian British

White

Mixed

Chinese or Other

 Caribbean

 African

 Other Black background


 Indian

 Pakistani

 Bangladeshi

 Other Asian background



 British

 Irish


 Other White background

 White and Black Caribbean

 White and Black African

 White and Asian

 Other Mixed background



 Chinese

 Any other



Where ‘other’ is ticked please provide further information:      

Gender




 Male  Female

Age




 15 or under

 16 – 17

 18 - 24


 25 - 34

 35 – 44



 45 – 64

 65+


Sexual Orientation




 Heterosexual  Homosexual  Bisexual

Religion




     

Status




 In education

 F/T employed

 P/T employed

 Retired

 Unemployed


 Looking after home or family

 Out of work due to sickness/disability

 Carer

 Other (please specify)      







Reference No. _________

Volunteer monitoring information


Disability




Under the Equality Act 2010 a person is defined as disabled if they have a physical or mental impairment which has a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities.
Would you consider yourself to be disabled as defined under the Equality Act 2010?
 Yes  No

If you have answered yes to the above question, please indicate which category best describes your disability:


 Hearing


 Sight
 Speech impairment
 Learning difficulties

 Mental health


 Physical/motor disability
 Language disability
 Other (if other please specify):      


Please return completed form to:



     

Office use only:

Date received:      

Location Code: VDL

Notes:

     


Version Number: 01 Date:16 August 2011




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