Volunteer Form

Reference (official use only) _________________

Volunteer Application Form

 (All information will be treated in confidence)

Surname: ______________               Forename:_________________Mr/Mrs/Miss/Ms

Address:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Telephone:                 Home:______________________________________________

Mobile: _____________________________________________

Email: ______________________________________________

Occupation: ______________________ Date of Birth: _________________________

Next of kin:  _____________________    Relationship to you: ___________________

Phone No: _________________

Do you have any medical condition/illness that might affect your work as a volunteer?  If yes, please give details:

___________________________________________________________________________

Are you engaged in other voluntary work?  Please give details?

___________________________________________________________________________

How did you hear about the IMNDA? _____________________________________

Why have you chosen to seek a volunteering opportunity with the IMNDA?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Have you had any experience, personal or otherwise, with MND?  Have you had any experience of persons who have been bereaved by MND? Have you suffered a recent loss?  If yes to any of these questions, please let us know what your experience has been and how long ago it was:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Time availability

We ask for volunteer to commit to a morning or afternoon or evening depending on the event

Number of hours per week ___/ two weeks_____ / three weeks_____ / month______

Do you have computer/admin skills? ___________________________

(Computer skills can be helpful but are not essential)

Garda Vetting Referees (all applicants)

You will be aware that as we work with vulnerable people, we have to be very vigilant in all our recruitment activities for both paid staff and volunteers.

We will therefore ask you to complete a Garda vetting form before you begin work as a volunteer.

The IMNDA will then submit the garda vetting form on your behalf only if you are accepted as a volunteer on the programme.

Unfortunately Garda Vetting is not transferable between organisations.

This means that unless you have received Garda Vetting through the IMNDA in the last three years we will ask you to complete the form.

1. Name:_____________________________                Address: _____________________________

Telephone No: ______________________                            ______________________________            _

Position Held: _______________________                           _______________________________

Relationship to you: __________________

2. Name:_____________________________                Address: _____________________________

Telephone No: ______________________                            ______________________________            _

Position Held: _______________________                           _______________________________

Relationship to you: __________________

Please note your referees will be contacted before you start as a volunteer with us.

The Garda reference check will take place only if you are accepted as a volunteer with this programme.

Any other comments you would like to add:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

I declare that the information I have given is, to the best of my knowledge, true and accurate and that I understand that I will be subject to a Garda vetting check.

Signed: _____________________________

Date:_____________________________

Please return completed form to:

Fundraising Team

IMNDA

Coleraine House

Coleraine St

Direct Line:      01 8730 422

Email:  info@imnda.ie