Personal details

First Name *

Last Name *

Address One *

Add Two

City

Postcode *

Email

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Gender male female other

Marital Status married widowed divorced seperated single

Homephone

Mobilephone

Workphone

  Do you have a Car?   Do you consider yourself to have a disability?

Adjustments

Experience

Employment Status (choose one) Employed F/T Employed P/T Retired Unemployed Student

Housing Status (choose one) Home Owner Renting Private Landlord Renting Social Housing Living at home

Have you volunteered before?

Hobbies

Referred From: * Volunteer Information Event Community Champion Leaflet Newspaper or local magazine Social Media/Website Through a Friend or Colleague School/College/University Corporate Volunteering - NIHE Other

Other... *

Which of the following tasks can you help with?

Assistance with Appointments
Activity Reminder
Advice Appointments
Ambulance Booking
Delay Early Entrance into Residential/Nursing Home Care
Listening Ear
Medical Appointment Dental
Medical Appointment GP
Medical Appointment Optician

Companionship
Computer skills
Reminiscence work shop with Geraldine
Visiting client whilst in hospital

Finance
Assist to pay Bills
Assistance to access money
Spend Local Vouchers
Spend Local Vouchers

Home Visiting
Arts/Crafts/Reading
Assist to prepare to move to respite/ nursing home care
Befriending
Care for a pet
Occasional indoor tasks
Review
Sitting Service
Social Support Visits
Talking Therapies at Home

Household
Assistance to discharge/ prepare to discharge from hospital
Assistance with Online Shopping
Attendance at Client Review
Laundry
Occasional outdoor tasks
Post Office
Scoping

Medical
Accompany to A&E
Appointment reminder
Assistance to discharge / prepare for discharge from residential care
Collection of prescriptions/medications
Getting Better 1-2-1 Exercise Project
Medical Appointment Out Patients
Medical foot care
Talking Therapies at Home
Visiting client whilst in temporary nursing home placement

Outings
Getting Better Together Project
Introduction to a Day Centre
Introduction to a new group/service
Personal Shopping
Social Activity
Summer Scheme
Visit a Relative

Transport
Volunteer Driver

  Occasionally we may require support for one off tasks in an emergency situation. Would you be willing to provide assistance?

Availability

		Mon	Tue	Wed	Thur	Fri	Sat	Sun
Morning
Afternoon
Evening

  Availability variable (may be able to work any of the above depending on circumstance)

Availability comments