1. Full Name *

 

2. Address *

 

3. Email Address *

 

4. Mobile Number *

 

5. Landline Number 

 

6. Are you willing to sign up to the Code of Conduct and Declaration of Interests? *

 

7. Are you willing to have your name published as a Healthwatch Volunteer? *

 

8. Have you ever had a criminal conviction? *

 

9. Are you willing to undertake a DBS check? *

 

10. Do you wish to apply for an exemption from attending training workshops on Enter & View or Safeguarding? If yes please upload a statement for panel consideration *

 

11. File upload for training exemption

Choose File
 

12. Why are you applying to be a Healthwatch Volunteer? (Max. 200 words) *

 

13. Are there any areas of health and social care you feel you have experience or expertise? Either as a commissioner, provider or user. (Max. 200 words) *