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 , 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 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 and USA – Miami Children’s Hospital (Florida); Texas Children’s Hospital (Texas) UK – , , , , , , , Newcastle,

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