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1
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Which role would you like to volunteer for?
Check-in and Chat
Community Drivers
Shop Assistants
Community Connectors
Office Administrator
Telephone Signposting
Personal Details
First Name
*
Last Name
*
Date of Birth
*
Telephone Number
*
Mobile Number
*
Email address
*
How would you prefer to be contacted?
*
Phone
Email
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Address
Address line 1
*
Address line 2
*
Address line 3
Address line 4
Postcode
*
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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
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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?
*
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Driving Licence
Name on Licence
*
Expiry date of Licence
*
Driving Licence Category
*
B
BE
C1
C1E
C
CE
D1
D1E
D
DE
Number of years held
*
Details of car to be used
Make and Model
*
Colour
*
Registration number
*
Number of Seats
*
Not including driver
Number of doors
*
Year of Manufacture
*
Insurance
Insurance Company Name
*
Insurance Policy Number
*
fully comprehensive Insurance
*
I have fully comprehensive Insurance
informed my insurance
*
I have informed my insurance company of my intention to volunteer as a Voluntary Car Driver and they have no objection to me doing so
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Our Minibus
Would you be willing to drive our minibus?
*
Yes
No
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Health Record
Are you in good health?
*
Yes
No
Do you require any workplace adjustments in order to undertake your work?
*
Yes
No
Please provide details below:
I am prepared to undergo a medical examination /occupational health assessment if required to do so.
*
Yes
No
Please tick the boxes as applicable
I am well and have no symptoms
I am well and have no symptoms like a cough or high temperature and neither does anybody in my household
I do not have any long-term health conditions
I do not have any long-term health conditions that makes me vulnerable to Coronavirus
I am under 70
I am under 70
I am not pregnant
I am not pregnant
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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
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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
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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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