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* 1. Title

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* 2. Please provide your name and contact information

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* 3. Which Volunteer Role are you interested in? (You can tick more than one)

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* 4. This would be work experience/placement

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* 5. Emergency Contact information

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* 6. I have permission to share these details

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* 7. What is your availability? Tick all that apply

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* 8. Is there any specific times where you will be unavailable on the day/s specified above? This can include if you are only available every other week or if you have specific times on the days where you ticked above, where you will not be able to volunteer.

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* 9. Please tell us why you wish to volunteer with Healthwatch?

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* 10. Please tell us what you are hoping to achieve or gain by volunteering with healthwatch?

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* 11. Please can you tell us any of any experience, skills and knowledge that you can bring to the role?

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* 12. Rehabiliation of Offenders Act (1974) -
All volunteers are required to undergo an Enhanced Disclosure and Barring Check. Having a criminal conviction does not preclude you from being a volunteer and will be decided on a case by case basis.

Do you have any convictions, cautions, reprimands or final warnings which are not ‘protected’ as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013)

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* 13. If YES, please provide details of your criminal record below.

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* 14. Please can you declare if there are any other roles or relationships which may be a potential conflict of interest (For example, if you are a local councillor or if you are related to a Board member)

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* 15. Please give details of TWO referees who have known you for last two years. Referees can be work related or personal, although not a family member


Referee 1

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* 16. Referee 2

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* 17. I have permission to share these details

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* 18. Declaration

I declare the information in this application is true and accurate. I understand that any failure to declare relevant information or to provide false information could result in my application being rejected and my volunteer role withdrawn.

I understand and agree that, as part of volunteering for Healthwatch, my details will be held on a confidential database that will only be used for reasons relating to my volunteering and this form will be filed in my confidential personnel file. All information about me will be held in accordance with the Data Protection Act 2018.

I am aware this application is for a voluntary role only and is not for and will not lead to paid employment. I understand and agree that both I and Healthwatch do not intend for any employment relationship to be created, either now or at any time in the future.

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