Volunteer Application Form (HR-F001C)

VOLUNTEER APPLICATION FORM (HR-F001C)

⏱ Takes about 15 mins. Have your Employment Dates & Referees ready. Progress is lost if you close the browser.

APPLICATION FOR VOLUNTARY PLACEMENT

Volunteer Application Form (HR-F001C)

It is a criminal offence for barred individuals to apply for regulated activity with vulnerable adults.

SECTION 1: PERSONAL DETAILS

Title

Staff_ID

Staff Member Name

Telephone/Mobile

Operating Local Authority

Date of Birth

Current Address House/ Flat Name

House/Flat Number

Post Code

Date Moved In

London Borough of

Driving License Status

Own Transport

SECTION 2: RIGHT TO WORK & IMMIGRATION STATUS

Are you a British Citizen?

Immigration / Visa Status

Share Code (Home Office)

Do you have any work restrictions?

SECTION 3: VOLUNTEER ROLE APPLIED FOR & LOCATION

Which Voluntary Role(s) are you interested in?

Geographical Preference

SECTION 4: SKILLS, COMPETENCY & FIELD COVER CHECKLIST

As a dynamic domiciliary care agency, our office and management team occasionally provide emergency field cover, field spot-checks, or staff training. Please complete the administrative sections, and declare any clinical competencies if you are willing/qualified to act in a dual capacity.

Core Competencies & Skills

Core Regulatory & Governance Competencies (Select all in which you are highly proficient)

Operational Management & HR Skills

Digital Software & Systems Proficiency

What is your experience level in leading or assisting with CQC Inspections or Local Authority Audits?

Quality Assurance & Continuous Improvement

Specialist Tasks

PEG / Enteral Feeding

Medication Administration (MAR Charts)

Stoma Care

Stroke Rehabilitation Support

Catheter Care

Dementia Care (Positive Behaviour)

Diabetes / Insulin

End of Life / Palliative Care

SECTION 5: EMPLOYMENT & VOLUNTEER HISTORY

Employer Name & Address

Add Employment 2?

Job Title

Add Employment 3?

Description of Duties

Add Employment 4?

Dates (From - To)

Add Employment 5?

Reason for leaving (as applicable)

Add Employment 6?

Add more employment history?

Employer Name & Address

Job Title

Description of Duties

Dates (From - To)

Reason for leaving (as applicable)

Add more employment history 3?

Employer Name & Address

Job Title

Description of Duties

Dates (From - To)

Reason for leaving (as applicable)

Add more employment history 4?

Employer Name & Address

Job Title

Description of Duties

Dates (From - To)

Reason for leaving (as applicable)

Add more employment history 5?

Employer Name & Address

Job Title

Description of Duties

Dates (From - To)

Reason for leaving (as applicable)

Add more employment history 6?

Employer Name & Address

Job Title

Description of Duties

Dates (From - To)

Reason for leaving (as applicable)

Have you ever been dismissed or subject to disciplinary?

Please provide details of dismissal/disciplinary

Explanation of Employment Gaps

SECTION 6: EDUCATION & QUALIFICATIONS

Highest Level of Education

Relevant Professional Qualifications

Training Certificates Obtained

Other Trainings

Professional Development

SECTION 7: SUPPORTING STATEMENT

Why do you want to Volunteer for Mutima Care specifically?

Describe your experience with administrative organization, customer service, or coordinating schedules

How do you ensure confidentiality and data protection when handling sensitive information?

SECTION 8: REFERENCES

Current/ Most Recent Employer

Job Title & Company

Professional Email Address

Telephone Number

Character/ Personal

Job Title & Company

Email Address

Telephone Number

Add another referee?

Additional Referee 3

Job Title & Company

Email Address

Telephone Number

Please note: We are required to obtain a reference from your most recent employer, and any previous health/social care employers.

SECTION 9: MEDICAL QUESTIONNAIRE

Do you require any reasonable adjustments to attend an interview?

Please specify any reasonable adjustments we can make

SECTION 11: REHABILITATION OF OFFENDERS & DBS

Current DBS Status

Are you currently included on the Children’s or Adults’ Barred List?

Have you ever been convicted of a criminal offence? (Spent or Unspent)

Please provide details (or state that you will provide them in a sealed envelope):

This role requires working with vulnerable adults. You must declare ALL convictions and cautions (even if 'spent') unless they are legally protected.

SECTION 10: SOURCE OF APPLICATION

How did you hear about this vacancy?

SECTION 12: DECLARATION

I confirm all information is accurate; false claims will result in dismissal. I agree to the mandatory DBS Update Service subscription and consent to Mutima Care processing my data.

Digital Signature (Type Full Name)

Date

Next Review Date:

APPENDIX: EQUAL OPPORTUNITIES MONITORING (Optional)

Ethnic Group

Gender

Religion or Belief

Age Band