Healthwatch St Helens Volunteer Application Form

Name *

Address

Postcode

Telephone Number (Landline)

Telephone Number (Mobile)

Email Address

Date OF Birth

Gender Other

Which Volunter Role Would You Like To Apply For *

Volunteer Healthwatch Champion

Volunteer Enter and View Authorised Representative

Volunteer Healthwatch St Helens Representatives

Please tell us a little bit about why you want to apply for the volunteer role above

Background Information: Please give brief details of any experience or training, which might be useful.

Have you ever been convicted of a criminal offence, which may affect your suitability to volunteer?

Yes

If yes please give details

(Please note that a Disclosure & Barring check will be necessary)

Do you have any additional needs that we need to be aware of?

Yes

If yes please give details

Referees

Please give the name and address of two referees. Your referees may be representatives from your current employment or voluntary placement. Otherwise from non-family members who have known you for a period of two years or more. Please ask the referees' permission first.

Contact Details for Referee One

Name

Address

Telephone Number

Email Address

Relationship to Referee

Contact Details for Referee Two

Name

Address

Telephone Number

Email Address

Relationship to Referee

Healthwatch St Helens is committed to Equal Opportunities and welcomes applications regardless of race, colour, nationality, sex, sexuality, marital status, caring responsibilities, age, physical, sensory or mental disability, or unrelated criminal conviction.

The information contained in this form will be kept on file for a period of time and we will ensure all information is kept confidential and in accordance with current Data Protection Legislation.

Declaration

I certify that, to the best of my knowledge, the information provided is correct and that by clicking "submit" constitutes a legal signature.

Declaration *

Yes

Tell us your views about local health and social care services:

0300 111 0007

[email protected]

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Healthwatch St Helens Volunteer Application Form

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