HELPFORCE COMPANIONS - VOLUNTEERS REGISTRATION FORM v.2

Thank you for your interest in volunteering with UPG and the Helpforce Companions project at Bush Doctors practice.

Helpforce Companions provide additional support to vulnerable patients at a local GP surgery.

We need to ensure safeguarding procedures for you and the patients. Please complete the questions below and if you need help with the form or more information, please contact the Coordinator (details at the end of the form).

Your offer to help local community members is much appreciated!

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* 1. Your details:

First name

Last name

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* 2. Your address:

Line 1

Line 2

Line 3

Post Code

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* 3. Your contact details:

Mobile

Landline

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* 4. In case of emergency, please give us a contact of someone close to you (name and phone number):

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* 5. Do you have a recent enhanced DBS certificate?
(Helpforce Companions are required to have a DBS as you will support vulnerable people. If you don't, we will arrange one and cover the cost of your application).

Yes - Certificate number and date it was issued:

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* 6. Your age group:
(You must be over 18 to volunteers as a Helpforce Companion).

18-24

25-34

35-44

45-54

55-64

65+

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* 7. What kind of task could you help with? (Please tick all that apply)

Telephone reminders (for example, to remind a patient about their medical appointment)

Telephone befriending

Escorting (for example, to GP practice and hospital appointments, local community services)

Shopping and delivery - essential items/prescriptions

Walking companion (physical exercise)

Gardening (outside areas)

Anything else you can help with that is not listed here?

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* 8. Please indicate your weekly availability (tick all that apply):

	AM (8 AM to 12 noon)	PM (12 noon to 5 PM)
MON	MON AM (8 AM to 12 noon)	MON PM (12 noon to 5 PM)
TUE	TUE AM (8 AM to 12 noon)	TUE PM (12 noon to 5 PM)
WED	WED AM (8 AM to 12 noon)	WED PM (12 noon to 5 PM)
THU	THU AM (8 AM to 12 noon)	THU PM (12 noon to 5 PM)
FRI	FRI AM (8 AM to 12 noon)	FRI PM (12 noon to 5 PM)
SAT	SAT AM (8 AM to 12 noon)	SAT PM (12 noon to 5 PM)
SUN	SUN AM (8 AM to 12 noon)	SUN PM (12 noon to 5 PM)

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* 9. What other languages can you speak? (Please select all that apply)

Amharic

Arabic

French

Oromo

Persian / Farsi

Polish

Portuguese

Somali

Spanish

Tagalog / Filipino

Tigrinya

Other (please specify)

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* 10. What is your current occupation?

Full-time student

Working part-time

Working full-time

Unemployed, but looking for work

Unable to work

Retired

Other

If other, please specify:

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* 11. What is your level of education?
(This is for guidance only, in case you are interested in training opportunities offered to Helpforece Companions).

GCSE or equivalent (Level 2 vocational qualification)

A Level or equivalent (Level 3 vocational qualification)

College or University

Postgraduation

Other (please specify)

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* 12. How did you hear about Helpforce Companions at Bush Doctors?

Bush Doctors GP surgery

Addison Community and Maternity Champions

Locality Matters

Social Media

Urban Partnership Group hubs (Masbro Centre, Edward Woods, White City)

Other (please specify)

DATA PROTECTION:

All personal data is stored securely and relevant personal information will only be shared with authorised staff to support your volunteering role.

For more information on our data protection policy click here www.upg.org.uk/privacy-policy

HELPFORCE COMPANIONS COORDINATOR:

Barbara Shelton - Addison Community Champions
Email: barbara@upg.org.uk
Phone: 07921 404 873

Urban Partnership Group
Masbro Centre
87 Masbro Road, London W14 0LR

Reg Charity 1092258 Reg Company No 3446256

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* 1. Your details:

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* 2. Your address:

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* 3. Your contact details:

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* 4. In case of emergency, please give us a contact of someone close to you (name and phone number):

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* 5. Do you have a recent enhanced DBS certificate? (Helpforce Companions are required to have a DBS as you will support vulnerable people. If you don't, we will arrange one and cover the cost of your application).

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* 6. Your age group:(You must be over 18 to volunteers as a Helpforce Companion).

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* 7. What kind of task could you help with? (Please tick all that apply)

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* 8. Please indicate your weekly availability (tick all that apply):

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* 9. What other languages can you speak? (Please select all that apply)

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* 10. What is your current occupation?

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* 11. What is your level of education?(This is for guidance only, in case you are interested in training opportunities offered to Helpforece Companions).

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* 12. How did you hear about Helpforce Companions at Bush Doctors?

* 5. Do you have a recent enhanced DBS certificate?
(Helpforce Companions are required to have a DBS as you will support vulnerable people. If you don't, we will arrange one and cover the cost of your application).

* 6. Your age group:
(You must be over 18 to volunteers as a Helpforce Companion).

* 11. What is your level of education?
(This is for guidance only, in case you are interested in training opportunities offered to Helpforece Companions).