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Children’s Advocacy
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Reach
Get Involved
Student Placements
Volunteering
Vacancies
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Contact Us
Home
About us
Advocacy
Our Achievements
Feedback
Comissioning Us
Our Services
Services – Staffordshire
Care Act
DoLS & Paid Representation
Independent Mental Capacity Advocacy (IMCA)
Independent Mental Health Advocacy (IMHA)
NHS Complaints
Disability Partnership Board
Professional Referral
Services – Stoke
BME/BAME
Care Act
Children’s Advocacy
DoLS & Paid Representation
Independent Mental Capacity Advocacy (IMCA)
Independent Mental Health Advocacy (IMHA)
Independent Visitors
NHS Complaints
Parental Advocacy
Professional Referral
Reach
Get Involved
Student Placements
Volunteering
Vacancies
Referrals
Contact Us
Volunteer Application Form
Volunteer Application
ABOUT THE VOLUNTEER:
Full Name
*
Date of Birth
*
Permanent Address
*
Postcode
*
Phone number(s)
*
Email address
Communication (please detail any communication adjustments you may need)
Have you been a volunteer before?
Yes
No
If yes, who with and when:
Driving (Tick all that apply):
*
I do not drive
I am a driver
I have my own, or access to, a vehicle
The vehicle is insured for business use
Employment status:
Employed- full time
Employed- part time
Unemployed
Voluntary worker
In Education
Retired
Other
Occupation (if applicable):
Employer (if applicable):
Availability:
*
Area of interest: - please choose one or more
*
Independent Visitor for a young person in care
Mental health
Learning Disability
Physical disability
Adults
Children and young people
BAME
Supporting parents whose children are involved with social services
Supporting people to raise complaints about their healthcare
Administration
Other
Interests/hobbies (Asist will try to match Independent Visitors and children with similar interests)
*
Skills and qualities
*
Have you got experience with adults with support needs and/or children or young people? Please provide details.
*
Reasons for volunteering with Asist
*
Reference (please provide details of someone willing to give a character reference. Referees should not be related to you)
*
Name: Tel No: Email: Address: Relationship to you:
Gender
Female
Male
Female, Male at birth
Male, Female at birth
Non-binary
Prefer not to say
Not listed,
please specify:
Not listed, <b>please specify:</b>
Pronouns
She/her
He/him
They/them
Sexual orientation
Heterosexual
Bisexual
Lesbian or gay
Prefer not to say
Not listed,
please specify:
Not listed, <b>please specify:</b>
Communication
English
Other spoken language,
please specify:
Other spoken language, <b>please specify:</b>
British Sign Language
Words/pictures/Makaton
Gestures/expressions/vocalisations
No obvious means of communication
Not listed,
please specify:
Not listed, <b>please specify:</b>
Ethnic origin
Arab / British Arab
Asian / British Asian
Black / Black British
Gypsy / Roma / Traveller
Mixed heritage
White British – English, Welsh, Scottish, N. Irish
White Irish
White other
Prefer not to say
Not listed,
please specify:
Not listed, <b>please specify:</b>
Religion or belief
Atheist (no religion)
Christian (all denominations)
Buddhist
Sikh
Hindu
Jewish
Humanist
Pagan
Muslim
Not listed,
please specify:
Not listed, <b>please specify:</b>
Person’s own description:
Person’s own description:
Do you identify as having a disability or long-term health condition?
Yes
No
Do you require any reasonable adjustments from Asist?
Yes
No
Consent
Due to GDPR (2018), we need authorisation to say that people agree to Asist holding their personal information included on this form.
I confirm that the information on this referral is correct.
*
Yes
No
Do you have a criminal background?
*
Yes
No
I consent to an enhanced DBS check.
*
Yes
No
How did you hear about us?
*
Other:
*
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