Volunteer - Expression of Interest Form
Pregnancy, Birth and Beyond peer supporters
Contact Details
Surname
Forename(s)
Area
Please select...
Isle of Dogs
Essex
Derby
Address
Postcode
Email
Landline telephone (home)
Mobile
How did you hear about us?
Personal Details
What are your main reasons for thinking about becoming a peer supporter?
Please give some details about yourself (this is your opportunity to tell us about the skills and experience you have).
Do you have any lived experience relating to mental health issues? (e.g. yourself, partner, family or friends)
Please select...
Yes
No
Are you a parent?
Yes
No
Do you speak any other languages apart from English?
Yes
No
If yes, please select the languages you can speak.
French
Spanish
Arabic
Mandarin
Hindi
Bengali
Portuguese
Russian
Turkish
German
Other Language
If others, please list:
Availability
If you have been given dates for the 4 week taster course, can you attend them all?
Yes
No
N/A
Please select from below ALL the times when you are normally available to attend a training session. Note - AM (9.30-12.30), Midday (11.30-14.30), PM (18.00-21.00). (Hold CTRL to select more than one option)
Please select...
Monday AM
Monday Midday
Monday PM
Tuesday AM
Tuesday Midday
Tuesday PM
Wednesday AM
Wednesday Midday
Wednesday PM
Thursday AM
Thursday Midday
Thursday PM
Friday AM
Friday Midday
Friday PM
Saturday AM
Saturday Midday
Saturday PM
Please tell us of any holidays or other commitments you have in the next few months.
If you went on to train to become a peer supporter after attending the taster course, how much time in your week would you want to commit to supporting local parents?
We welcome applications from people with disabilities; please list any actions we may need to take to support you in attending our training e.g. access requirements.
Have you ever received a conviction or caution for a criminal offence?
Yes
No
If yes, please specify full details below.
Equal Opportunities
The following questions are optional. They are asked for monitoring purposes only and will not be used in any way to assess your suitability for the volunteering role.
Date of Birth
Gender
Male
Female
Prefer not to say
If you have gained any qualifications, please tell us the highest qualification you have gained.
Ethnicity
Please select...
White British
White Irish
White European
Any other White background
Black Caribbean
Black African
Any other Black background
Indian
Pakistani
Bangladeshi
Any other Asian background
White & Black African
White & Asian
White & Black Caribbean
Any other Mixed background
Chinese
Any other background
Prefer not to say
Arab
If you selected 'Any other background', please provide details:
Age Group
Please select...
0-14
15-24 years
25-34 years
35-44 years
45-54 years
55-64 years
65-74 years
75-84 years
85 years +
Religion or Belief?
Buddhist
Christian
Hindu
Jewish
Muslim
No religion/atheist
Other (please state)
Other (prefer not to say)
Sikh
If you selected 'Other (please state)', please provide details:
Sexual Orientation
Heterosexual / Straight
Gay Man / Lesbian Woman
Bisexual
Other
Prefer not to say
Employment
Employed - full time
Employed - part time
Student - full time
Student - part time
Maternity leave
Retired
Unemployed - seeking work
Preferred choice to be a parent
Not employed - carer
Not employed - health reasons
Other
Select the option that best describes your situation.
x
If you selected 'Other', please state details below
Under the terms of the Equality Act 2010, a person has a disability if s/he has a physical or mental impairment which has a substantial and long term adverse effect on his/her ability to carry out normal day to day activities.
Do you consider yourself to have a disability as defined in the Disability Discrimination Act?
Yes
No
Prefer not to say
The information that you have given us will be used and stored by us in line with the data protection legislation. Great care is taken to ensure that personal information cannot be accessed by unauthorised personnel and that the Data Protection principles are adhered to. Your information will be used or held in the following ways: As part of our selection process for the taster course. For the purpose of monitoring and evaluation we may share some of the information with partner organisations and those who provide the funding for our programme. Great care is taken to ensure that individuals cannot be identified and only numbers are passed onto these organisations. Without mentioning your name, the information we collect helps to give feedback to these organisations about who is benefitting from our training programme and about volunteering opportunities. If you are offered a place on the course and go on to become a peer supporter then we will use the information you have provided as part of our peer supporter record keeping systems.
I declare that the information on this form has been supplied by me and is correct. I understand how the information on this registration form will be used, shared with others and stored by your organisation and I give my consent for this.
Print Name
Date
Contact Information