1. Name:
2. Address:
3. Postcode:
4. Email:
5. Telephone:
6. Date of birth:

1. Tick times and days when you are available:

   	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
   AM
   PM
   Evenings

   	Term time only
   	School/University/College holidays

2. Which volunteering opportunities are you interested in within NICHS?
   (Please note - There may be compulsory training in relation to your volunteer role.)

   Helping at Stroke scheme (Weekly)	Bus escort
   Befriender	Fundraising - support group
   Special events	Street collections
   Counting money	Ambassador for NICHS collecting cheques
   Attending presentations	Promoting work of NICHS

3. Other (please give details):

1. What motivation, experience, skills or abilities do you feel support your application to be a volunteer?

1. Do you have a chest, heart or stroke related illness? yes no
   If YES please advise your doctor of your intention to volunteer
   N.B. It is important to discuss with your doctor the appropriateness of this type of voluntary work.
2. Please detail any medical conditions that we may need to be aware of and / or any specific requirements that you will need, in order to volunteer.
3. Do you have use of a car & hold a current driving licence? yes no
   
4. How far are you willing to travel?
5. How did you hear about volunteering for NICHS?

Please provide two referees from people who have known you reasonably well for over 2 years, these should not, if possible, be close friends or direct relatives.

1. Name:
2. Relationship:
3. Address:
4. Postcode:
5. Email:
6. Telephone:

1. Name:
2. Relationship:
3. Address:
4. Postcode:
5. Email:
6. Telephone:

Your volunteering activity will involve working with vulnerable people in the local community. Consequently you are required by the rehabilitation of Offenders Act 1974 to declare all criminal convictions including those which are spent. This might not prevent you from volunteering with NICHS. Please note the information given will be treated in confidence and only taken into account in relation to this particular volunteering activity.

If required I also give my consent to a police check being carried out. (Access N.I. form to be completed.)

1. Do you have any convictions to declare (please give details of any convictions below)?
   yes no
   

   Date	Details

1. I confirm that the information on this form is correct and in accordance with the Data Protection Act 1998.
   
   I give my consent to NICHS, for the purpose of my volunteering, to process by computer, or other means, the information contained on this form.
   yes no