PEER SUPPORT VOLUNTEER
APPLICATION FORM
Thank you for your interest in becoming a Peer Support Volunteer at Auntie Pam’s. Please
complete this application form and return it to the address on page 5.
Please complete in BLOCK CAPITALS
PERSONAL DETAILS
Title:
Mr
Mrs
Miss
Ms
Forename:
Surname:
Date of Birth:
Address:
Telephone numbers
Home :
Postcode:
Mobile:
Email address
LANGUAGES
First language spoken:
Other language spoken:
EMPLOYMENT STATUS
Are you:
Currently employed?
Yes
No
In higher education?
Yes
No
Retired from employment?
Yes
No
Please indicate when you are able to help
Morning
Afternoon
Evening
Private and Confidential
Full day
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EMERGENCY CONTACT DETAILS
Title:
Mr
Mrs
Miss
Ms
Rev
Forename:
Telephone numbers
Surname:
Home :
Address:
Work :
Postcode:
Do you have any past or present voluntary experience?
Yes
No
If yes, please give details:
Why do you wish to undertake voluntary work within Auntie Pam’s?
How did you hear about volunteering with Auntie Pam’s?
Newspaper
Volunteer bureau
Poster
Friend
Present volunteer
Private and Confidential
Website
Other
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REFEREES
Please indicate below the names and addresses of two referees, (NOT RELATIVES) who may be contacted:
Referee 1:
Title:
Mr
Mrs
Miss
Ms
Forename:
Telephone numbers
Surname:
Home :
Address:
Work :
Postcode:
Are you known by any other name by this referee? Yes
No
If yes, please type other name here:
Referee 2:
Title:
Mr
Mrs
Miss
Ms
Rev
Forename:
Telephone numbers
Surname:
Home :
Address:
Work :
Postcode:
Are you known by any other name by this referee? Yes
No
If yes, please type other name here:
CONFIDENTIALITY
All volunteers are asked to sign an agreement to maintain confidentiality, with regard to any
personal/medical details about residents/patients before commencing voluntary work.
Signature:
Date:
Thank you for completing this form!
Private and Confidential
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Please read the following information carefully and sign below as directed.
Protection Act.
If whilst a volunteer you are police cautioned, given final warning or reprimanded or are subject to any
police investigation you must inform the Auntie Pam’s Project Officer immediately.
DATA PROTECTION ACT
As you have provided personal information to Kirklees Council on your application for voluntary service,
this form seeks your consent for us to use the information provided.
The Data Protection Act (1998) (the Act) sets out certain requirements for the protection of your personal
information against unauthorised use of disclosure.
The Act also gives you certain rights.
By signing this page as part of your application for Voluntary work, you consent for Kirklees Council to
use and keep this information about you, provided by you or third parties, such as referees, relating to your
application.
Such information may include details relating to your health or ethnic origin. If your application is
unsuccessful, or you choose not to become a volunteer, then the information will not be held for longer
than is necessary, after which time it will be destroyed. However, some relevant information may be
retained in the longer term to facilitate our equal opportunities monitoring.
If your application is successful, the information will form part of your file and we will be entitled to
process it for all purposes in connection with your voluntary activities.
You will need to bring with you a photographic record of your identity (passport, new style driving
license, student ID or bus pass).
I CONSENT TO THE USE OF MY PERSONAL INFORMATION FOR THE PURPOSES STATED
AND ON THE TERMS SET OUT ABOVE.
Signature: __________________________________
Full Name (printed): ___________________________
Date: ______________________________________
Private and Confidential
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THE KIRKLEES COUNCIL FAIR PROCESSING INFORMATION NOTICE
This notice is given to volunteers so that Kirklees Council can comply with its obligations under
the Data Protection Act 1998. (The Act).
Kirklees Council needs to keep information about you for purposes connected with your
voluntary service, including your application. The sort of information we will hold will relate to
your voluntary activities with the Council. It will include information for expenses, references,
contact names and addresses, training and health records, and information about the activities
you have undertaken and where. We believe these uses are consistent with the principles of the
Act.
The information we hold will be for our management and administrative use only but we may,
from time to time, need to disclose some information we hold about you to relevant third parties
(e.g. where legally obliged to do so or where requested to do so by you for the purposes of giving a
reference). We would seek your consent to do so, prior to disclosing any information where
necessary. We may also keep information about your health for the purposes of: compliance with
our health and safety obligations; for considering how your health affects your ability to do
volunteer activities and, if you are disabled, any adjustments to be made to assist you. If you have
provided it the Council keeps information about your racial or ethnic origin and disability status
for the purpose of monitoring the provision of equal opportunities. If you need to know what
information is kept about you then the Council will tell you and explain why it is kept.
Please Return to:
FREEPOST RTAY-XJZK-STGL
Lisa Akester
Auntie Pam’s
9 Northgate
Dewsbury
WF13 1DS
Mark the envelope – Private and Confidential
Private and Confidential
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