IN YOUR PRIMEVolunteer Registration Form Your Details Title (required) First Name (required) Surname (required) Address (required) Town/City (required) County Postcode (required) Phone No. (required) Email (required) Volunteering Details Why are you interested in volunteering? (Please tick all that apply) I want to help othersI have spare time and want to use it productivelyI have skills and experience I can bring to CrossroadsI want to keep my mind and body activeOther (please specify) Do you feel you have any skills that you could share with others? What areas of work are you interested in? BefriendingTelephone ServiceEmergency TransportOrganising EventsIntergenerational ActivitiesFundraisingOther (Please Specify) How did you hear about Crossroads In Your Prime project? Word of MouthPosters / LeafletsInternetOther (Please Specify) What is your availability? (required) Access NI Crossroads is a registered body with Access NI and has a legislative requirement to comply with their Code of Practice. The Code is intended to ensure that information released in disclosures is used fairly and to provide assurance to applicants that this is the case. The Code also seeks to ensure that sensitive personal information is handled and stored appropriately and kept only as is necessary. Full details of Access NI Code of Practice can be found on their website: www.dojni.gov.uk/accessni Do you have a current Enhanced Disclosure Certificate? yesno If yes, please give your Enhanced Disclosure Certificate Number: Are you currently or have you ever been the subject of proceedings by the NISCC or being referred for any reason whatsoever to the Disclosure and Barring Service (DBS), previously known as the Independent Safeguarding Authority (ISA), for barring consideration? yesno If yes, please provide full details to include dates and the outcome of these proceedings. Please write these on a page with your name at the top and place in a sealed envelope marked with your name and mark it confidential for the attention of Volunteer Co-Ordinator. Please note that you are required to inform us if you are or have been the subject of a referral to the Disclosure and Barring Service (DBS), previously known as the Independent Safeguarding Authority (ISA), for barring consideration, even if the outcome was not to bar. Do you have any prosecutions pending? yesno Have you ever been convicted at a court or cautioned by the police for any offence? yesno If yes, please list below details of all charges, prosecutions, convictions, cautions or bindover orders, including ‘spent’ convictions. You must also include any minor matters, any road traffic or motoring offences. Give us as much information as you can, including, if possible, the offence, the approximate date of the Court Hearing and the Court which dealt with the matter.