Radio Lollipop South Africa Volunteer Application Form

APPLICATION FORM Application to become a full volunteer at a Branch of Radio Lollipop South Africa Thank you for your interest in joining Radio Lollipop in South Africa. Please complete this application form and return it to your nearest Radio Lollipop station. You will find the address on page 3. Please answer all questions in capital letters and use a black pen OR complete electronically. Thank you. Full Name (Mr/Mrs/Miss/Ms) _____________________________________________________________ Permanent Address ____________________________________________________________________ ____________________________________________________________________________________ Tel no. Home _________________________ Tel no. Mobile _____________________________ Tel no. Work __________________________ Email ____________________________________ Date of Birth _________________________ Gender (please tick) Male ☐ Female ☐ Occupation (with dates) _________________________________________________________________ How did you hear about Radio Lollipop? ____________________________________________________ ____________________________________________________________________________________ Every Radio Lollipop Volunteer commits a minimum of 1 session each week to working with the children and in addition would be expected to attend Volunteer meetings. What day(s) and time(s) would be most suitable for you? _______________________________________ ____________________________________________________________________________________ Have you had any serious illness in the last 3 years? __________ If yes, please give brief details: ____________________________________________________________________________________ Please give the details of two professional people who would be willing to act as references for you: Name ______________________________ Name ____________________________________ Occupation __________________________ Occupation _______________________________ Address _____________________________ Address __________________________________ ___________________________________ _________________________________________ Telephone ___________________________ Telephone ________________________________ Email _______________________________ Email ____________________________________ Volunteer Application Form SI-701/SA0916 V1c Page 1 of 3 Registered Charity in South Africa, Number 2016/420290/08 Registered Office: Radio Lollipop South Africa, 35 Ashford Road, Parkwood, Johannesburg 2132 Please use the space below to describe why you wish to join Radio Lollipop and to give any other information in support of your application such as leisure interests, relevant experience or qualifications. Please continue on another sheet if required. If you have a disability, do you require any reasonable adjustments to be made during the interview process? If so, please give details of adjustments required. _________________________________________________________________________________ _________________________________________________________________________________ Equality and Diversity Monitoring Form As a voluntary organisation working within our partner hospitals, Radio Lollipop is required to collect equality and diversity information. This information is collected to fulfil that obligation and is used for monitoring purposes only. It will enable Radio Lollipop to analyse the profile and make up of applicants in support of equal opportunities. Please complete the following: I would describe my ethnic origin as follows (please tick): Asian ☐ Black ☐ Caucasian ☐ Chinese ☐ Coloured ☐ Indian ☐ Other ☐ Volunteer Application Form SI-701/SA0916 V1c Page 2 of 3 Registered Charity in South Africa, Number 2016/420290/08 Registered Office: Radio Lollipop South Africa, 35 Ashford Road, Parkwood, Johannesburg 2132 Criminal Procedure Act (CPA), 1977 (Act 51 of 1977) In order to protect certain vulnerable groups within society we must ensure we adhere to the Criminal Procedure Act (CPA), 1977 (Act 51 of 1977). Radio Lollipop Volunteers are not entitled to withhold any information about convictions or other criminal record information. If you are successful with this application, any failure to disclose such convictions or criminal record information would result in instant dismissal from Radio Lollipop. Anyone applying for a position as a Radio Lollipop Volunteer is required to obtain a Police Clearance Certificate from the South African Police (further information is available online at: http://www.saps.gov.za/services/applying_clearence_certificate.php) Any Information you provide will be held confidentially. Date Nature of Offence Date ‘spent’ No offence committed (please tick if applicable) ☐ Declaration I declare that the information I have provided on this form is true and accurate (please tick) ☐ Signed _______________________________________ Date __________________________ Thank you for completing this form, would you please now return it to your nearest Radio Lollipop Station: Karabo Lechela Radio Lollipop Nelson Mandela Children’s Hospital Corner Victoria Avenue and Jubilee Road Parktown Johannesburg South Africa 2193 E-Mail: [email protected] Radio Lollipop also operates in: Australia – various locations throughout the states of Queensland and Western Australia New Zealand – various locations in and around Auckland and Christchurch USA – Miami Children’s Hospital (Florida); Texas Children’s Hospital (Texas) UK – Birmingham, Bristol, Dundee, Edinburgh, Glasgow, London, Manchester, Newcastle, Southampton The information given on this form will be stored for membership administration purposes only. The information provided for this application will remain totally confidential to Radio Lollipop and if you are unsuccessful then the data will be securely destroyed after 7 months. Further information can be found on our website at www.radiolollipop.org Volunteer Application Form SI-701/SA0916 V1c Page 3 of 3 Registered Charity in South Africa, Number 2016/420290/08 Registered Office: Radio Lollipop South Africa, 35 Ashford Road, Parkwood, Johannesburg 2132 .

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