Personal Details

Name*

Date of Birth*

*Phone Number

Email*

Address*

School/Youth Organisation

If you attend school/college and/or a youth organisation please provide details here.

Which area/s of Health and Social Care are you most interested in or have experience of? E.g. Mental Health, Asthma, Dental Care.

Why do you want to volunteer for Amplify?

What can you bring to the role you are applying for? Any specific skills

What do you think is the biggest issue facing young people in Blackburn with Darwen?

Parent/Carer Consent & Emergency Contact*If you are under 16 please provide details of a parent/carer who supports your volunteer application & can be contacted in an emergency. If you’re over 16 please provide details of someone who can be contacted in an emergency.

I am under 16 years old

I am 16 or older

Name*

Relation to you*

*Phone Number

Email*

Address*

Image consent

In accordance with the Data Protection Act 1998 and GDPR, we need your permission before any photos and audio/visual recordings of you are used in promotional materials. We will not share images or audio/visual recordings taken of you with any external organisations, unless you give us permission to do so.

I give/do not give(delete as appropriate) my permission for images and audio/visual recordings of me to be used by Healthwatch Blackburn with Darwen using images (photo and video) of me in its printed publications websites and social media sites, for information, advertising, marketing and promotional purposes.

Signed*Enter your name

Date*Today Date

Supporting statement

Please let us know one professional person e.g. teacher, youth worker, employer or family friend who can write a statement supporting your application

Name*

How do you know this person?*

*Phone Number

Email*

Address*

Thank you for your interest in volunteering for Amplify and for spending time completing this form.

Amplify Volunteer Application Form

Personal Details

School/Youth Organisation

Image consent

Supporting statement