Making Connections | Volunteer Form

Surname *

First Name *

Date of Birth: *

Occupation: *

Your address: *

E-mail: *

Telephone: *

Where did you hear about Making Connections? *

If employed, what company do you work for (company name + location)? (we may have a volunteer programme with your organisation). *

Previous Volunteering/Community experience (if any): *

Hobbies/Skills/Interests that may be relevant: *

What attracted you to volunteer for Making Connections? *

Would you prefer to visit a man or woman (or no preferences)?

Will you visit someone who has pets? *

Will you visit a smoker? *

Mode of transport? *

Anything foreseeable to interrupt your weekly visits in the coming 9 months? *

Morning

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Sun

Afternoon

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Evening

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South Dublin

Blackrock (Blackrock, Deansgrange, Bootertown) Dun Laoghaire (Dun Laoghaire, Dalkey, Sallynoggin,

South Dublin 2

Monkstown, Glenageary) Ballybrack (Ballybrack, Killiney, Loughlinstown, Shankhill,

South Dublin 3

Johnstown, Kilternan,Carrickmines, Cabinteely, Cornelscourt)

South Dublin 4

Dundrum (Dundrum, Rathfarnham, Goatstown) Stillorgan (Stillorgan, Churchtown, Milltown, Mount Merrion)

Name: *

Job Title: *

Email: *

Telephone: *

Address *

Name: *

Job Title: *

Email: *

Telephone: *

Address: *

Do you have any medical condition or illness that might affect your work as a volunteer? (please tick box if 'yes')

If yes, please give details:

Name: *

Telephone: *

Address: *

7+6 *

STEP 1

ADDITIONAL INFORMATION:

YOUR AVAILABILITY

REFERENCES:

Reference 2

MEDICAL:

NAME AND ADDRESS OF NEXT-OF-KIN WHOM WE MAY REFER IF NECESSARY: