Volunteer registration: Interests and preferences

Please take a few minutes to look through the following lists. The areas of interest and the activities that you choose will help us to match you with appropriate volunteering opportunities. 1. Please select any of the following that interest you: Patient Public Involvement in Health Forum (PPIF) Black and Ethnic Minority Volunteer Organisations ( BME-Health Sector) PALS- Patient Advisory Liaison Service Social Care Institutions eg Hospitals, Primary Care Trusts Type of Activity: Please select any of the following that you would like to do: Forum Member - NHS Hospital Trust Public Patient Involvement In Health Forum member - Primary Care, Public Patient Involvement In Health Forum member -Ambulance Trusts Public Patient Involvement In Health Forum member -Care Trust Patient Public Involvement Forum member -Mental Health Trust Public Patient Involvement In Health Members Management Committees & Trusteeship of Black and Ethnic Minority Voluntary Organisation Volunteer member of PALS- Patient Advisory Liaison Service (Campaigning, Lobbying and Advocacy) (Social Care) Health Education Working with the Elderly Helping/supporting families Helping people with disabilities Working on wards/departments within hospital Health Advocacy Mental Health institutions Befriending/welcome volunteer Chaplaincy helper Outdoor Activities eg gardening Expert patient programme volunteer Not Sure   If you do not know which PPI forum you would like to be a member of please select here:   2. Please select each box when you could be available as a volunteer.   Mon Tue Wed Thu Fri Sat Sun AM PM EVE 3. If you would like to volunteer for a Hospital or Primary Care Trust - Please state below which Hospital or PCT you would like to volunteer for in your local area. 1) 2) 3)

4. Do you have any specific need for when you come to meet us? (eg translator, lip speaker, wheel chair access?) If so please furnish the details of the preferred help (eg. Translater - Mr Anon, address, postcode, contact details)     5. How did you hear about CEMVO- National Health Volunteering Programme? Advertisement Local Press National Press Leaflet Recommendation Other If Other Specify

Volunteer registration: Information to promote greater social inclusion (Private and Confidential).

(Answers given to these questions form part of our policy of promoting greater social inclusion. If you do not wish to answer these questions, skip to the next section)

1. What is your current employment status?(Please select)

Employed Non employed House-person Retired Student Unable to work Unemployed

2. Which ethnic group do you feel you belong in? (Please select one)

Black Caribbean Bangladeshi White Irish Chinese Other White background Indian Other Mixed background Pakistani Black African Turkish White & Black African European White & Black Caribbean Other Asian background Black British Other background (please specify below) Other Black background

3. Nationality 4. Date of birth : 5. Religion : 6. Do you consider yourself disabled? Yes No If Yes are you: - Registered Self classified 7. Sexuality (optional) Heterosexual Bi-sexual Gay Lesbian Transsexual Other Other

8. Is there anything else you would like to tell us about yourself?

Volunteer account creation: Curriculum vitae.

Please enter your CV here: (if you have one)

or Browse and select your cv (doc and rtf files only)

Volunteer account creation: Declaration

I confirm the information on my application is true. I understand that if I am appointed and the information is found to be false, then my PPI or PALS or voluntary position membership may be ended. I agree all terms and conditions.