Volunteer Application Question Title * 1. Title OK Question Title * 2. Please provide your name and contact information Name * Address * Address 2 City/Town * State/Province ZIP/Postal Code * Country * Email Address * Phone Number * OK Question Title * 3. Which Volunteer Role are you interested in? (You can tick more than one) Healthwatch Administrator Volunteer Children and Young Person's Volunteer Community Engagement Volunteer Community Champion Volunteer Enter and View Ambassador Independent Stretegic Advisory Board (ISAB) Mystery Shopper Reading Panel Volunteer Sector Champion Volunteer Support Mentor OK Question Title * 4. This would be work experience/placement Yes No OK Question Title * 5. Emergency Contact information Name Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number OK Question Title * 6. I have permission to share these details Yes No OK Question Title * 7. What is your availability? Tick all that apply Monday Tuesday Wednesday Thursday Friday Saturday Sunday OK Question Title * 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. OK Question Title * 9. Please tell us why you wish to volunteer with Healthwatch? OK Question Title * 10. Please tell us what you are hoping to achieve or gain by volunteering with healthwatch? OK Question Title * 11. Please can you tell us any of any experience, skills and knowledge that you can bring to the role? OK Question Title * 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) Yes No OK Question Title * 13. If YES, please provide details of your criminal record below. OK Question Title * 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) OK Question Title * 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 Name * Address * Address 2 City/Town * State/Province * ZIP/Postal Code * Country * Email Address * Phone Number * OK Question Title * 16. Referee 2 Name * Address * Address 2 City/Town * State/Province * ZIP/Postal Code * Country * Email Address * Phone Number * OK Question Title * 17. I have permission to share these details Yes No OK Question Title * 18. DeclarationI 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. I agree OK DONE
