Volunteer Referral Form

1. Your Details

First Name

Last Name

Date of birth

Address

City

County

Post Code

Phone/text number

If using video call which do you use?

FaceTime

Zoom

Other - please specify

Email address

How can we best contact you?

Phone

Text

Other Notes:

2. How did you find out about the Volunteer role?**

Other:

3. What type of support can you offer?**

Other:

4. What interests, hobbies and skills do you have?

Please attach a copy of your CV if you have one.

Choose File

5. When can you volunteer?

Times available for volunteering?

Restricted availability (i.e. can’t do)?

6. In-person Support

The service is intended to be remote (video calls) however some members may ask for in-person support. You do not have to offer this support and we will pay agreed travel expenses.

If you are willing to offer in-person support, how would you travel to visit service users? If you do not wish to offer in-person support, you do not have to answer this question.

Own Car / Bike

Public Transport

Walking

Cycling

How far are you willing to travel to visit service users? (in miles):

Less than 5 miles

5 - 10 miles

20 miles

7. Do you have a criminal record?

Yes

Protecting Children and Adults

Please be aware that some of our volunteering roles require a Disclosure and Barring Service (DBS). Some criminal offences will not bar you from volunteering with us and we will decide on an individual basis.

However, offences including any form of violence, theft or blackmail will automatically disqualify you from volunteering to support vulnerable adults or children.

If yes, please give details/dates of offence(s) and sentence(s).

Is there anything that may stop you working with vulnerable adults?

Yes

If yes, please give details

8. References

Please include 2 references that we can contact after your informal assessment.

One of your references should be someone who knows you in a professional capacity, such as work, volunteering or education.

1st Referee

First Name

Last Name

How do you know the them?

Address

Address Line 1

City

County

Postcode

Phone/Mobile

2nd Referee

First Name

Last Name

How do you know them?

Address

Address Line 1

City

County

Postcode

Phone/Mobile

9. Emergency Contact

This must be completed if you would like to support people in-person.

First Name

Last Name

How is this person related to you?

Address

City

County

Post Code

Phone/Text Number

How can we best contact them?

Phone

Text

Other notes:

10. Equality and Diversity

Self Help Nottingham and Deaf Cancer Support aims to be open and inclusive to all. We welcome diversity in our team and will make all reasonable adjustments to support anyone volunteering with us. We will try to provide access, equipment, or other practical support to ensure that our volunteering opportunities are accessible as possible. We work within the Equalities Act 2010 and welcome volunteers from all backgrounds and circumstances.

Do we need to make any specific arrangements in order for you to attend the interview or undertake your preferred role?

Yes

If yes, please give details

11. Ethnicity **

The questions below are for us to monitor the diversity of our volunteering team to ensure that we are representing the communities we work in. You are under no obligation to complete the questions, but it would help us to continue working to make our service accessible to as many people as possible.

Please state (any other Ethnic Group):

Mixed / Multiple Ethnic Groups

White and Black Caribbean

White and Black African

White and Asian

Any other mixed/multiple ethnic background

Please state (any other Ethnic Group):

Black / African / Caribbean / Black British

Caribbean

African

Any other Black/African/Caribbean background

Please state (any other Ethnic Group):

Any other Ethnic Group

Arab

Prefer not to say

Any other Ethnic group

Please state (any other Ethnic Group):

12. How would you describe your gender identity?**

Self describe your gender identity

13. How would you describe your sexuality?**

Self describe your sexuality

Declaration**

I give my consent to be contacted and for the above information to be held by Self Help UK (SHUK) for the Macmillan Deaf Cancer Support Project (DCSP). If you do not consent to be contacted, we will not be able to continue with your application. In accordance with GDPR, we will store these details securely, only use them for the MDCSP and will retain them for up to 7 years after your application. If you no longer wish to volunteer and would like your information to be deleted, please contact [email protected]

SORD (Social Research with Deaf People)

Some of this information (marked with **) will be shared with Social Research with Deaf People (SORD) who are evaluating this project, but only if you have consented to take part in the evaluation study.

SORD would like to send you some information about the evaluation study so that you can decide if you want to take part.

This information is in BSL (and English) - https://www.deafcancersupport.org.uk/evaluation

Yes

If you tick 'Yes' it means that we will pass on your email/contact details to SORD. We will NOT pass on any other information about you.

Volunteer Referral Form

1. Your Details

2. How did you find out about the Volunteer role?**

3. What type of support can you offer?**

4. What interests, hobbies and skills do you have?

5. When can you volunteer?

6. In-person Support

7. Do you have a criminal record?

Protecting Children and Adults

8. References

1st Referee

2nd Referee

9. Emergency Contact

10. Equality and Diversity

11. Ethnicity **

12. How would you describe your gender identity?**

13. How would you describe your sexuality?**

Declaration**

SORD (Social Research with Deaf People)

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