Section 1 – Personal Contact Details

First Name

Last Name

Email

Telephone

Address (including Postcode)

Are you over 18 Are you over 18 Yes No

Additional information - If you are under 18

Date Of Birth (DD/MM/YYYY)

School Name

Current School Year

Section 2 – Emergency Contact Details

First Name

Last Name

Email

Telephone

Address (including Postcode)

Relationship of contact

Volunteer Roles

Requested Role (Please indicate) Requested Role (Please indicate) Activity Volunteer Café Assistant Volunteer Creative Display Volunteer Meet, Greet and Front Desk Shelver Other

Please tell us why you would like to volunteer in the library and any relevant skills or experience you have.

Is there anything that may limit the tasks you are able to do, for example mobility problems, difficulty with lifting or carrying, inability to stand for long periods?

Section 3 – Availability

How much time do you have available to volunteer? Please give the number of hours/days per week:

Please indicate your preferred times for volunteering:

Weekday Weekday Tuesday AM Tuesday PM Wednesday AM Wednesday PM Thursday AM Thursday PM Friday AM Friday PM

Weekend Weekend Saturday AM Saturday PM

Preferred start date (DD/MM/YYYY)

Is this for Duke of Edinburgh work experience? Is this for Duke of Edinburgh work experience? Yes No

Participation dates

Date start

Date finish

Section 4 – Referees

Please give the name and address of two people whom we may contact for a reference (not family members), one should be a professional or work-related reference. Please note that we will contact these referees prior to the start of your volunteering. If this is a work experience placement from a secondary school you only need to provide one reference from the school that you attend.

First referee

Name

Relationship

Telephone

Email

Second referee

Name

Relationship

Telephone

Email

Section 5 – Data Protection Statement

The information that you provide on this form and that obtained from other relevant sources will be used to process your application for volunteering at Blackfen Community Library. I understand that my data will be held and treated in accordance with the Blackfen Community Library Privacy Policy. The information that you provide on this form and that obtained from other relevant sources will be used to process your application for volunteering at Blackfen Community Library. I understand that my data will be held and treated in accordance with the Blackfen Community Library Privacy Policy. I agree that Blackfen Community Library can hold my data.

Section 6 – Self Declaration Statement

Self Declaration Agreement – Blackfen Community Library is committed to the safeguarding of children and vulnerable adults. I understand that before I become a volunteer I will need to read, sign and date a self declaration form. Self Declaration Agreement – Blackfen Community Library is committed to the safeguarding of children and vulnerable adults. I understand that before I become a volunteer I will need to read, sign and date a self declaration form. I understand and agree to the terms

Dated (DD/MM/YYYY)