Contact the Elderly - Volunteer Application Form

VOLUNTEER DRIVERS ONLY

Make and type of car

Registration Number

Number of seats

Number of seatbelts

Number of doors

Insurance Comprehensive

Third Party Only

License Full

Provisional

Details of any endorsements

VOLUNTEER HOSTS ONLY

No stairs and only a few steps are required, and a downstairs toilet

How many steps to be negotiated?

Do you have a downstairs toilet?

Please give details of parkling at your home?

VOLUNTEER DRIVERS/COORDINATORS ONLY

Please give details of two non-family members who will provide a personal reference for you?

FIRST

Full Name

Full Address

Telephone

Relationship

SECOND

Full Name

Full Address

Telephone

Relationship

ALL APPLICANTS

Data Protection Act

I understand and agree that, as part of a Contact the Elderly Group, my details will be held in a confidential database that is only used for communications within the Charity.

I confirm that the above information is correct and that I agree to my details being held as set out above.

Please tell us where you heard about Contact the Elderly?

If you know of anyone who might be interested in receiving more information about Contact the Elderly, please provide details below and we will send information to them.

Full Name

Address

Telephone

Relationship