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APPLICATION FORM
Age NI Peer Facilitator

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* 1. DOB:

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* 2. Referees: Please provide details below of TWO referees, who should be individuals who have known you either in a professional capacity or a community capacity.  Please note they should not be relatives or close friends.

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* 3. Referee 2

ADDITIONAL INFORMATION

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* 4. Please explain why you would like to volunteer as a Peer Facilitator?

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* 5. One of the key qualities of an effective Peer Facilitator is the ability to listen to others from an impartial point of view.  Please outline your experience of being an effective listener

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* 6. Please include below any additional information in support of your application

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* 7. Please detail any medical conditions that we may need to be aware of and/or any specific requirements that you will need, in order to volunteer:

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* 8. Emergency contact: Please provide details of someone we could contact in case of an emergency:

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* 9. Filtering and Criminal Conviction Information

  Yes  No 
Do you have any convictions that are not 'protected' as defined by the Rehabilitation of Offenders (Northern Ireland ) Order 1978, as amended in 2014?
Is there any reason you cannot work with adults in regulated activity?
Personal Declaration

I declare that all the foregoing statements are true and complete to the best of my knowledge and belief.

I understand that any wilful misstatement or omission renders me liable to disqualification.

I understand that I will undergo a full Access NI security check if successful in joining  Age NI as a Peer Facilitator

Age NI reserves the right to verify any information provided

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* 10. Please acknowledge you have read personal declaration

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* 11. By providing your details you are agreeing to us contacting you in the future. If you prefer we don’t contact you in future please tick the preferred box below.

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