Become a Befriender Form - Parkinson’s Care and Support UK

Parkinson’s Befriender Application Form

Title*

Name*

Address*

POST CODE*

D.O.B*

Tel*

Email*

Do you have Parkinson’s?*

Yes

If yes, how long have you had the condition?

If no, what is your connection with Parkinson’s?

1. Please give us why you want to volunteer as a Befriender and give us a brief outline of any volunteering or other experience that you consider may be useful to this role. *

2. Also detail any hobbies and interests you have to help us with a match.*

3. Please let us know:

Which ways you are able to connect with your befriendee (eg Telephone, ZOOM, Skype, WhatApp etc)?*

How often and when you would like to do telephone calls/ have contact e.g weekly, daytime etc.?*

Would you be willing to have more than one befriendee to call? If so how many? *

4. If possible, describe your ideal befriendee

5. Please provide any further details that you think we should be aware of.

Please provide names, addresses and telephone numbers of two Referees who we can contact to ask about your suitability for the role. We will contact your referee by phone or email, so please ensure you have given us one or both of these.

Reference 1

Name*

Contact Number*

Email*

How they know you*

Reference 2

Name*

Contact Number*

Email*

How they know you*

I confirm that all the details on the application form are correct and accurate*

Confirm