Volunteer application form :: Derbyshire Community Health Services

Application to become a DCHS volunteer

Please complete this application form and check it carefully before pressing submit.

We will review your form and get in touch to make sure we understand what you are looking for and there is a volunteer vacancy that matches your request.

If we are able to progress your application you will then be asked to complete an equality, diversity and inclusion monitoring form. This enables us to ensure we are recruiting fairly and representing the diversity in our community.

About you

Your title

Your first name (s) Required

Your family name Required

Your address

Address 1

Address 2

City

State/Province

Country

Postal Code

Your contact number (This is the number we will use to contact you.) Required

Date of birth Required

Your email address Required

Volunteer role

Your availability: How many hours are you able to give to this role? (number of hours per week, times of the week, e.g. morning, afternoon, evening, or weekend and for what duration, e.g. minimum 6 months) Required

Tell us about any volunteering experience or any previous employment you have that is relevant? Required

Are there any particular skills you would like to develop by volunteering with DCHS? Required

Pre-volunteering Health Declaration

In order to ensure compliance with pre-placement checks required within the NHS, with current disability legislation and to ensure that DCHS provides you with any support during your work experience we need you to respond to the following statement.

**Conditions which may be relevant include back injury, skin disease, epilepsy, diabetes or psychological illness.

If 'yes', we will discuss your particular situation and any reasonable adjustments at the next stage of the application process.

I do have a health condition or disability which might affect my volunteering and which might require special adjustments to my placement or at the location of my placement.** Required

Yes

References

Who should you ask to be your referee? We suggest this is your previous employer/volunteer supervisor, a religious or cultural leader, teacher or tutor, case worker, social worker or community leader.

Referee 1

Title Required

Full name (first name and family name) Required

Address

Address 1

Address 2

City

State/Province

Country

Postal Code

Contact number Required

Email address Required

Job title Required

What is your relationship with the referee? Required

Referee 2

Title Required

Full name (First name and family name) Required

Address

Address 1

Address 2

City

State/Province

Country

Postal Code

Contact number Required

Email address Required

Job title Required

Rehabilitation of Offenders Act 1974

The Rehabilitation of Offenders Act 1974 (as amended) helps rehabilitated ex-offenders back into work by allowing them not to declare criminal convictions after the rehabilitation period set by the Court has elapsed and the convictions become 'spent'. During the rehabilitation period, convictions are referred to as 'unspent' convictions and must be declared to employers.

Have you any unspent criminal convictions or bind overs, or any cautions, warnings or reprimands? Required

Yes

If yes, please supply details below.

Agreement/signature of volunteer applicant

Required

The information in this form is true and complete. I agree that any deliberate omission, falsification or misrepresentation in the form will be grounds for rejecting this application.

Volunteer application form

Application to become a DCHS volunteer

About you

Volunteer role

Pre-volunteering Health Declaration

References

Referee 1

Referee 2

Rehabilitation of Offenders Act 1974

Agreement/signature of volunteer applicant

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