Ref number……………………………………………………………………..
Office use only
Ref 1 sent date: ……………………….. DBS Sent Date: …..……………....
Ref 2 sent date: ……………………….. DBS approved: Yes / No
Ref 1 received date: ………………….. DBS ref no………………..……..…
Ref 2 received date: ………………….. Database
Disability Awareness Training Attended Date: …………………….………..
Safeguarding Training Attended Date: ……………………………….………
Volunteering Start Date:
VOLUNTEER APPLICATION FORM
Surname First name
Address
Postcode Male Female
Tel No Mobile
Age category: under 18/18-24, 24-35, 35+ Email address
Preferred method of communication Email Phone Post
Work/School/College attending
When are you available to volunteer? Please tick when you can volunteer (we understand this may
change)
Day DAY TIME EVENING WEEKLY FORNIGHTLY HOLIDAYS
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
When are you available to volunteer till i.e., school, college, university, ongoing
Please provide details of two referees. Referees cannot be a family member and must be over
18
It is preferable, where possible, if one referee is your current or previous employer
Name Name
Address Address
Post Code Post Code
Email Email
Tel No Tel No
Relationship Relationship
Where would you like to volunteer:
Amber Valley Erewash Derby City Derby Dales South Derbyshire
Which age group are you interested in working with:
Children aged 0 – 18years Young People aged 18 – 30 years
Equal Opportunities
Umbrella operates an equal opportunity policy. To help us monitor its effectiveness, please complete
this section. A statement of the policy is included in the recruitment guidance.
Choose ONE section from A to E, then tick the appropriate box to indicate your cultural
background:
White B. Mixed
British White and Black Caribbean C. Asian, Asian British, Asian
English White and Black African English, Asian Scottish or
Scottish White and Asian Asian Welsh
Welsh Any other Mixed
Irish background Indian
Any other White Please write in Pakistani
background Bangladeshi
Please write in Any other Asian
background
Please write in
D. Black, Black British, Black E. Chinese, Chinese British,
English, Black Scottish or Chinese English, Chinese
Black Welsh Scottish, Chinese Welsh
or other ethnic group
Caribbean
African Chinese
Any other Black Any other Asian
background background
Please write in Please write in
Personal Statement
Have you ever been discharged from employment on health or medical grounds? If yes,
please give details Y/N
Have you ever been refused employment on health or medical grounds? If yes, please give
details Y/N
Do you have any ill health requiring treatment or care from a specialist? If yes, please give
details Y/N
Do you require any reasonable adjustments to be made to allow you to carry out the role?
If yes, please give details Y/N
Do you consider yourself Disabled? If yes, please give details
Y/N
Please let us know if you have any additional support needs to enable you to volunteer and we will do
our best to meet these.
Declaration
Have you ever had any personal contact with the Social Care Department, NSPCC or Children First in
connection with children in your care?
………………………………………………………………………………………………………………………..
Have you ever been dismissed from any paid or voluntary work?
…………………………………………………………………………………………………………………..
If you have answered yes to any questions, Volunteer Services will contact you to discuss this further.
Due the role you are applying for an enhanced DBS will be completed prior to you being able to
volunteer.
This post has substantial access to children and/or vulnerable adults and as such, entitles Umbrella to
make enquiries of employees and is subject to an enhanced record check with the Disclosure and
Barring Service (DBS check).
The amendments to the Exceptions Order 1975 (2013) provide that certain spent convictions and
cautions are ‘protected’ and are not subject to disclosure to employers, and cannot be taken into
account. If you are successful at interview, your appointment will be subject to a check regarding
criminal convictions and whether there has been a disqualification from working with children/adults.
In this case you will be provided with a further questionnaire via email and will be required to pay the
initial fee.
Failure to complete the DBS check will result in the job offer being withdrawn. The DBS will check the
information you provide below.
Do you have any convictions, cautions, reprimands or final warnings that are not “protected” as
defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in
2013)?
Yes No
If yes, please give brief details:
Nature of offence(s)…………………………………………………………………………………………….
Date of convictions(s) Penalty…………………………………………………………………………………
How did you hear about Umbrella and what do you want to gain from volunteering with us?
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
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Declaration by Applicant
I declare to the best of my knowledge I have made no statement in this application that is false or
misleading. I understand the truth of this declaration will be a condition of my selection by
Umbrella, and that any false or misleading information given may constitute grounds for dismissal
at a later date.
Signed:…………………………………………… Date:……………………………………..
If volunteer is under 18 years old, parent/ carer to sign consent.
I give permission for my child to volunteer for Umbrella. I understand that there are various
opportunities available, and may be offered to volunteer on several of these opportunities.
I also give my consent for my child’s photograph being taken and used in the Volunteer Services
Project or Umbrella Publicity Yes No
Parent/ Carer ………………………………………………………………………………………………..
Signature……………………………………………………………………………………………………
Date ………………………………………………………………………………………………………...
General Data Protection Regulations
Any data about you will be held in secure conditions with access restrictions. Data will be used for volunteer
monitoring purposes (equal opportunities section only) and will not be shared with anyone outside of
Umbrella. If you’re application for volunteering is declined for any reason, your application will be destroyed
after a period of 12 months. If you join the Umbrella team, this form will be used as part of your personnel
record.
For further information please see the privacy statement on our website www.umbrella.uk.net
Please tick to give consent for the following:
I give my consent for my details to be shared for external sources for Volunteer nominations; this may include
places such as Derby CVS and southern Derbyshire CVS ….. Yes….. No
I give my consent for photographs to be taken of me and to be used where we feel appropriate to
advertise Umbrella. This may include such places as Facebook, promotional material, Websites
etc… ….. Yes ….. No
Please attach 2 passport sized pictures to your application
Please return this form to;
Volunteer Services Co-ordinator
Umbrella House
64 Birdcage Walk
Mackworth
Derby
DE22 4LD
