Name

Address

Telephone

Emergency phone numbers

Any particular health needs you have

(only state if you choose to)

References

Do you have a current driving licence?

Yes

Which local areas suit you best?

What work or training have you done

Do you have any pending or unspent

conviction? If so, please give details

Under the Rehabilitation of Offenders Act

(one could be your GP)

(two people who have known you from

work or training)

No

Do you have use of a car?

Yes

No

which may be relevant?

1974, you are required to give details of

convictions, even any unspent ones

Information is kept in strict confidence

and will not necessarily preclude you

from volunteering.