*Full name (including middle names):
*I have lived at this address since (mm/yyyy):
*Daytime contact number:
Evening contact number:
*Date of birth (dd/mm/yyyy):
May we keep your details on computer?
Do you have a hearing loss?
If yes, do you use a hearing aid?
Do you have the use of a car? (Not essential).
If yes, would you be willing to use your car for voluntary work?
What is your current Status? (E.g. in waged or non-waged employment, retired, housewife, etc.)
When would you like to volunteer? Please state, morning, afternoon, particular day of the week.
Which of our volunteer services interest you? (Please tick as many as you wish from the list below)
Local Resource Centre Assistant
Equipment Follow-up Volunteer
Assistant Loop Installer
What other voluntary activities, if any, have you been, or are you currently involved in?
What are your life experiences and achievements, whether paid or voluntary?
Do you have any special skills; hobbies or languages you feel would be useful while volunteering?
What is your interest or motivation in volunteering with us?
References - Please give the names of two referees, not related to you, one of whom should be a professional person, such as a doctor, teacher, employer, religious leader, etc. The other can be a neighbour or personal friend. If your referees know you by another name, e.g. your maiden name, please let us know.
Although we are a Charity, we have a duty to protect the vulnerable people we help. Please give details of any criminal convictions, cautions or bindovers, if any, excluding minor motoring offences. Please use a separate sheet if necessary.
Please note; all applications will be subject to current Criminal Records Bureau (CRB) procedures.
We want you to feel comfortable when discussing volunteering. You may wish to indicate your preferred location to meet. (Please tick as appropriate)
Local Volunteer Centre
In your own home
Local Citizens Advice Bureau
How did you hear about the volunteering opportunities with Hertfordshire Hearing Advisory Service? (please tick)
Citizens Advice Bureau
Local CVS Office
Word of mouth
If other, please specify
I confirm that the information given above is, to the best of my knowledge correct. I accept that any relevant information falsely given or withheld may prejudice my application or subsequent approval. Please print your name in the box as confirmation.