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Which role would you like to volunteer for?

Personal Details

First Name*

Last Name*

Date of Birth*

Telephone Number*

Mobile Number*

Email address*

How would you prefer to be contacted?*

Phone

Email

Address

Address line 1*

Address line 2*

Address line 3

Address line 4

Postcode*

Please tick the boxes as applicable

I am well and have no symptoms

Response level 1 - Involves collecting shopping or other essential supplies for someone who is self isolating, and delivering these supplies to their homes

I do not have any long-term health conditions

Response level 2. -This role involves transporting equipment, supplies. and/or medication to between services, sites and homes, it may involve pharmacies with medication deliveries

I am under 70

Response level 3 -This role provides transport to frail people with unmet transport needs who are medically fit for discharge and ensuring that they are settled backing their own homes or people who want to go to an essential appointment that is not respiratory related

Disclosure and Barring Service

Are you registered with the DBS Update Service? *

Yes

No

This role is subject to an enhanced DBS check. Please confirm you are happy to undertake the appropriate checks: *

Yes

No

Have you had safeguarding training?*

Yes

No

What year did you receive this training?*

Have you had Passenger Assisting Training (PATS)?*

Yes

No

What year did you receive this training?*

Our Minibus

Would you be willing to drive our minibus?*

Yes

No

About you

Please tell us why you would like to be considered for this role, your interests, skills and experience?

Please provide any other information which will help us match you with passengers:

e.g. can your car boot accommodate walking frames?

Are there any days/times you would definitely prefer not to drive?

Are you willing/able to drive the same clients on a regular basis?

Yes

No

Referee 1

Please provide details of 2 referees. Where possible, one referee should be a recent employer or professional who knows you well.

First Name

Last Name

Telephone Number

Email address

Address

Postcode

Referee 2

First Name

Last Name

Telephone Number

Email address

Address

Postcode

Data Protection Notice

I understand that any information given on this application form may be held on computer or elsewhere and falls within the provision of the Data Protection (Bailiwick of Guernsey) Law, 2001. In the event of being unsuccessful for this post, I understand that this application form with any attachments will be retained for a period of 12 months and then destroyed.

I agrees to the data processing notice and Health Connections Terms and Conditions

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Which role would you like to volunteer for?

Personal Details

Address

Please tick the boxes as applicable

Disclosure and Barring Service

Driving Licence

Details of car to be used

Insurance

Our Minibus

Health Record

Please tick the boxes as applicable

About you

Referee 1

Referee 2

Data Protection Notice

Services

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Volunteer Roles

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