St Georges Lupset Ltd.

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Young Helper Application Form

Post Title *

Personal information

Mrs

Miss

Other:

Clear selection

Surname/ Family Name

First Name(s)

Address

Telephone Number (Home)

Telephone Number (mobile)

Email Address (if provided this will be used for all correspondence)

Emergency Contact 1: Name and number (Include relationship to volunteer)

Emergency Contact 2: Name and number (Include relationship to volunteer)

The Main Reason for wanting to become a volunteer

To give something back to the community

As a means of meeting new people

For a new experience

To help job prospects

I need experience for education

To increase my confidence

Other:

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Health Record

Do you have any special needs that we could make provision for? (If yes, please specify)

Do you have any medical conditions that we should be aware of? (If yes, please specify)

Definition of disability under the Equality Act 2010 - You’re disabled under the Equality Act 2010 if you have a physical or mental impairment that has a ‘substantial’ and ‘long-term’ negative effect on your ability to do normal daily activities.

Do you have a disability? (If yes, please specify)

Availability - Please state when you are able to volunteer

Eve

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

References

Please provide the names of two referees. Ideally, they should be current or former employers. Alternatively, they must be over 18, not be directly related to you and you should have known them reasonably well for at least two years. ‘Reasonably well’ means meeting with them either socially or on business regularly. ‘Directly related’ means related by blood or marriage

Reference Number 1: Name/Relationship/Address/Postcode/Telephone/Email

Reference Number 2: Name/Relationship/Address/Postcode/Telephone/Email

Rehabilitation of Offenders Act 1974 - Have you ever been convicted of an offence. If Yes, please provide details below *

Yes

Please provide details of offence(s) here:

Applicants will be judged on their ability to perform the duties of the post and convictions will only be considered if they are relevant to that type of work. You may be required to have a Disclosure and Barring Service check (DBS)

EQUAL OPPORTUNITIES STATEMENT

St George’s Lupset Ltd is an equal opportunities organisation. All applicants will be considered on the basis of suitability for the post, regardless of sex, race, marital status, religion, disability, or sexual orientation. In order to monitor the effectiveness and success of the policy, it is important that you complete the questionnaire below.
The details given in this part of the form are confidential and will not be considered in any way during the appointment process.

Age Group

Age

Ethnicity

Asian or Asian British - Bangladeshi

Asian or Asian British - Chinese

Asian or Asian British - Indian

Asian or Asian British - Japanese

Asian or Asian British - Pakistani

Black or Black British - African

Black or Black British - Caribbean

Black or Black British - other

Mixed - other

Mixed – White and Asian

Mixed – White and Black African

Mixed – White and Black Caribbean

White - British

White - European

White - Irish

Option 16

Another ethnic group

Do not wish to disclose

Clear selection

Gender

Female

Male

Prefer not to say

Other:

Clear selection

Consent

By signing this form, you are confirming that you are consenting to St George’s
Lupset Ltd holding and processing your personal data.
We need to have your personal details for you to access our services.

Please tick the boxes below that apply to you.
You can grant consent to all the purposes; one of the purposes or none of the purposes. Where you do not grant consent, we will not be able to use your personal data; (so for example we may not be able to let you know about forthcoming events); except in certain limited situations, such as where required to do so by law or to protect members of the public from serious harm. You can find out more about how we use your data from our “Privacy Notice” which is available on our website.

You can withdraw or change your consent at any time by contacting one of the Data Champions at St George’s Lupset Ltd or info@stgeorgeslupset.org.uk. Please note that all processing of your personal data will cease once you have withdrawn consent, other than where this is required by law, but this will not affect any personal data that has already been processed prior to this point.

To include my details on the St George’s Lupset Data base so that I can be contacted as needed as a volunteer. *

Yes

To keep me informed about news, events and activities at St George’s Lupset Ltd. I consent to St George’s Lupset Ltd contacting me by: *

Post

Phone

SMS

None of the above

I consent to the use of my photograph for purposes of celebration or publicity of the work at St George’s Lupset Ltd *

Yes

I consent to the use of my photograph on St George’s Lupset Ltd website or Facebook page. *

Yes

To share my contact details with other partner agencies of St George’s Lupset if required for the development of a particular service

Yes

Clear selection

In an emergency and if I can’t be contacted, I am willing for the young person to receive hospital treatment, including anaesthetic if necessary. I understand that every effort will be made to contact me as soon as possible.

Yes

Clear selection

Declaration

I certify that to the best of my knowledge that the information I have given is correct. I understand that any false information given on this form, including that relating to criminal convictions, may render an offer of voluntary service invalid and/or render me liable to instant dismissal for the post of Volunteer.

Yes

Name of Parent/Guardian/Carer on behalf of the Young Person *

YYYY

Submit

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