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:

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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):

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

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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?

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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