Volunteering Tool 3
Volunteer Registration Form
Personal details
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Title Mr Mrs Miss Ms Other (please specify)
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First name(s)
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Surname
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Email
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Contact address
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Postcode
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Tel Day Eve Mobile
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Volunteering with Marie Curie Cancer Care
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If you know what role or type of volunteering you would like to do, please give details.
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Availability
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How regularly do you wish to volunteer? Monthly Fortnightly Weekly More often
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When would you be available to volunteer?
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AM*
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PM*
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Evening
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Please tick the hours that you are available to volunteer, but note that not all roles are available at all times.
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Mon
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Tues
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Wed
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Thur
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Fri
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Sat
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*AM will normally be until 1pm and PM from 1pm
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Sun
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Additional information
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Are you under 18 years old? Yes No
If yes, please give your date of birth
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Do you have a current driving licence? Yes No
If yes, do you have the use of a car? Yes No
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Do have the right to volunteer in the UK? Yes No Not sure
If you are here on a visa, there may be restrictions.
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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.
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About you
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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.
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Special requirements
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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?
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References
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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.
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Referee one
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Referee two
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Name:
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Name:
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Address:
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Address:
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Telephone:
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Telephone:
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Email:
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Email:
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How do you know this person?
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How do you know this person?
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How long have you known them?
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How long have you known them?
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Data protection act
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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
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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
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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.
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Where did you hear about volunteering with Marie Curie Cancer Care?
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Ethnic Group
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Black or Black British
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Asian or Asian British
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White
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Mixed
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Chinese or Other
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Caribbean
African
Other Black background
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Indian
Pakistani
Bangladeshi
Other Asian background
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British
Irish
Other White background
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White and Black Caribbean
White and Black African
White and Asian
Other Mixed background
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Chinese
Any other
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Where ‘other’ is ticked please provide further information:
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Gender
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Male Female
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Age
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15 or under
16 – 17
18 - 24
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25 - 34
35 – 44
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45 – 64
65+
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Sexual Orientation
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Heterosexual Homosexual Bisexual
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Religion
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Status
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In education
F/T employed
P/T employed
Retired
Unemployed
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Looking after home or family
Out of work due to sickness/disability
Carer
Other (please specify)
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Volunteer monitoring information
Disability
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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
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If you have answered yes to the above question, please indicate which category best describes your disability:
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Hearing
Sight
Speech impairment
Learning difficulties
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Mental health
Physical/motor disability
Language disability
Other (if other please specify):
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Please return completed form to:
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Office use only:
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Date received:
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Location Code: VDL
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Notes:
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Version Number: 01 Date:16 August 2011
www.mariecurie.org.uk
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