Volunteer with Leeds Mind
Application Form – Befriending
For Admin use only
Date application received: ……………………..
References received (date)
Date references sent for: ……………………..
1:
DBS check Info sent:
………………………
2:
DBS check received:
...............................
Date Induction attended:
Service:
………………………………………
Date started volunteering:
The information you give in this form will be kept Private and Confidential in accordance with
Leeds Mind’s Confidentiality Policy. Information may be shared with any of the Leeds Mind
Services their managers, volunteer coordinators and potential supervisors and may be kept on file
for up to 6 months pending recruitment.
Please attach a passport sized photo to your application. This does not need to be an
actual passport photo but must be of good quality as it will be used on your volunteer ID
card should your application be successful.
Personal Details – Please PRINT clearly
Surname
Title
Date of Birth
Surname at Birth if different
Home tel.
First Name(s) (in full)
Work/Daytime tel.
E-mail address (please check carefully)
Mobile
Home address
Birthplace – Town as shown on your passport
Nationality
Emergency Contact Details
Name:
Relationship
to
you:
Telephone:
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References
Please give contact detail of two people who can act as referees for you. The referees should have known you
for 2 years if possible and should not be relatives or partners
Name:
Address:
Name:
Address:
Email:
Email:
State how you know this person:
State how you know this person:
Health declaration - In order to help us to assess any additional support required:
Do you have a health or behavioural condition or are you taking any medication
that could reasonably affect your ability to volunteer at Leeds Mind? (If yes, we YES/NO
may contact you to discuss)
Do you have a disability for which special arrangements or adjustments are
needed? (If yes, we may contact you to discuss)
Employment - Are you at present:
Employed:
Yes
No
Retired: Yes
No
Student: Yes
If employed please give your current
job title:
If retired please give your most
recent job title:
Service User: Yes
If service user, do you use Leeds Mind services?
No
YES/NO
No
If student please give your
course title:
Yes
No
Which service?...............................................
Declaration - Leeds Mind is covered by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975.
You must therefore disclose both current and spent convictions. Please note that providing this information
will not automatically exclude you from accessing our services. As Leeds Mind works with vulnerable adults
you will be required to undergo a CRB (Criminal Records Bureau) check before you can commence as a
volunteer. Information on how to progress this will be sent out to you separately.
Current /Spent Convictions
Do you have any Spent/current convictions?  Yes  No
Nature of Summons or Charge
Signed
If Yes, please give details below.
Sentence or Order
…………………………………………Date
…………………………..
Data Protection
We have asked you to provide information about yourself on this form. This information may be entered and
stored on a computer. We will keep any personal information you provide safely and confidentially and use it
only for the purpose for which it has been supplied, and will only be shared with others from Leeds Mind who
are involved with your volunteering placement. There are some circumstances where we have the right to
share personal information without your permission, for example to protect children or adults or to prevent or
detect crime.
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Please complete this page
How did you find out about volunteering at Leeds Mind?
Why would you like to become a volunteer with Leeds Mind?
What do you hope to gain from volunteering at Leeds Mind?
What relevant Skills and Experience would you bring to the Volunteering role you
are interested in?
This need not be paid work but can include voluntary work, student activities etc
Do you have a second language or BSL skills?
Please let us know if you speak any other languages than English and/or have other skills e.g. BSL
Availability- When are you able to volunteer?
We will try to match the volunteering opportunities available to when you want to volunteer
(egg. days, approximate amount of time, daytime / evening / weekends). We hope that
you will be able to do at least 3 hours per week
How many hours per week are you prepared to volunteer?..........................
Please return this form to:
:
cat.bailey@leedsmind.org.uk
:
Cat Bailey, Befriending Administrator, Leeds Mind, Clarence House, 11 Clarence
Road, Horsforth, LS18 4LB
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Leeds Mind
Diversity monitoring form (Volunteers)
As Leeds Mind is committed to being an Equal Opportunities Employer Leeds Mind, to ensure
good practice in this area we need to monitor the diversity of our staff and volunteers. To this end
we ask that you complete this form as part of your application to be a Volunteer with Leeds Mind
and return it with your Application Form All information given is treated as confidential and is
used for statistical purposes only
Ethnic origin
White
Mixed
British
White & Black Caribbean
Indian
Irish
White & Black African
Pakistani
Any other white
background
White & Asian
Bangladeshi
Any other mixed
background
Any other Asian
Background
Asian or British Asian
Black or Black British
Other ethnic groups
Caribbean
Chinese
African
Other ethnic
Background
Please state
Any other black
background
…………………………………..
Gender - What is your gender?
Sexual orientation
What is your sexual orientation?
Male / Female / Transgender*
Heterosexual
Lesbian
Bisexual
Gay
Other (please state) ………………………………
Disability - Do you have you a disability?
Hearing
Physical
YES/NO*
Speech
Sight
If Yes, Please indicate
Other
Please give details of your disability …………………………….……………………………………
Mental health
Do you have lived experience of mental health problems?
YES/NO*
Are you or have you been a carer for someone with mental health problems?
YES/NO*
*delete as necessary
Signed ……………………………………. Date ……………
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