Pitstone Community Car Scheme

VOLUNTEER REGISTRATION FORM

Thank you for giving your time to volunteer with the Pitstone Community Car Scheme. In order for us to support you as a volunteer there is certain information that we need to hold on file.

Please would you complete the below and return to the co-ordinator. 

Many thanks! We hope that you enjoy your time volunteering with us!

THIS FORM WILL BE TREATED AS CONFIDENTIAL INFORMATION.  

Personal Details

Title:  MR/MRS/MS        Name:

Name:	

Address:

Email:

	

Telephone Number:					Mobile Number:

Emergency Contact Details 

Please fill in the first box in with a next of kin and the second with a local contact, just in case you are taken ill or have an accident whilst volunteering.

First Emergency contact name:
Relationship to you:
Emergency contact address:  

Telephone number:                                                                   
	
Contact’s relationship to you:  

Second Emergency contact name:
Relationship to you:
Emergency contact address:   

Telephone number:                                                                   
	
Contact’s relationship to you:  

Do you have specific availability?

Please help us with the smooth running of the scheme by letting us know if you have specific dates or times that you are available/not available. Circle times when you are normally available.
  Mon    Tue	  Wed	  Thur	   Fri	  Sat	  Sun
  Am	  Am	  Am	 Am	  Am	  Am	  Am
  Pm	  Pm	  Pm	  Pm	  Pm	  Pm	  Pm
  Eves	  Eves	  Eves	  Eves	  Eves	  Eves	  Eves

Please feel free to provide us with more detail on your availability

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What kind of things do you fancy helping out with?                                                   Tick for ‘yes’                                                                                                                                                                                            
Lifts to local clinic/doctor’s appointments.	 	
Longer journeys e.g trips to further away hospitals.	 	
Could you carry a wheelchair in your car?	 	
Could you assist a wheelchair user/ put chair in the car?	 	

Could you help us with the behind the scenes admin work? 
       eg provide holiday cover for the co-ordinator                			    	     Y/N
Do you have any special skills or experience to offer?                         			     Y/N
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References
Please give details of an individual (not a family member) who has known you for at least  2 years and could provide a reference.  
First name:					Surname:
Address:
Postcode:                                             		Email:
Tel No (day):					           
How does this person know you?	

How did you find out about this volunteering opportunity?

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