GUILLAIN-BARRÉ & ASSOCIATED INFLAMMATORY NEUROPATHIES Application to volunteer Tel 01529 469910 (office hours Monday to Friday 9am-3pm) Email office@gaincharity.org.uk Website www.gaincharity.org.uk Registered charity nos. 1154843 & SCO39900 Your Details Your Name Date of birth Full address including postcode Your email Telephone If you have had GBS or are living with a chronic variant such as CIDP etc, please complete this section Your diagnosis Date of diagnosis Were you ventilated? Do you have ongoing issues related to this condition? If you are a family member of a person diagnosed with GBS or CIDP etc, pleas complete this section Relationship to patient Their diagnosis Date of diagnosis Were they ventilated? Although we receive occasional requests for one-to-one support, these are relatively few, and volunteers offering peer support may only be called upon very infrequently. There are however, lots of additional ways you can support the charity and people affected by these conditions, by raising awareness amongst health professionals, and by raising funds to help us deliver our services. What would you like to help with? Please indicate below all areas of volunteering that may interest you Providing peer support to patients and their families (this could be by phone, Skype / Facetime, messaging or visiting) YesNo Raising funds (be as imaginative as you like with this one!) YesNo Raising awareness by putting our leaflets in hospitals, etc YesNo Speaking to organisations / medical students, etc YesNo Organising a local gain2gether in your area YesNo IMPORTANT INFORMATION – please read We require our volunteers to have access to the internet, so information can be shared via an encrypted email service. It would also be beneficial if we can contact you on a smartphone via WhatsApp, which is a secure, free, encrypted messaging service. Please note, details of a third party (such as a request for support from a patient or their family, or feedback following contact) CANNOT be communicated via ordinary email channels as these are not encrypted and therefore do not comply with the General Data Protection Regulation (GDPR) guidelines effective from 25th May 2018 Do you have access to: A smartphone (Apple or Android) YesNo Internet YesNo WhatsApp YesNo Organising a local gain2gether in your area YesNo Skype / Facetime / other (specify) YesNo Please provide the names of two referees who we can contact in support of this application and have known you for at least 12 months (no family members) Name Address Relationship to you Name Address Relationship to you From time to time, we may request a DBS check for our volunteers. Are you happy for us to do this? YesNo General consent Here at GAIN we take your privacy seriously and will only use your personal information to administer your account and to provide the services you have requested from us. GAIN would like to keep in touch with you about the vital work we do to help those affected by GBS, CIDP & the associated inflammatory neuropathies; our campaigns to raise funds and awareness, local & national gatherings, opportunities to support us or take part in trials and research as well as the products you can buy. If you consent to us contacting you for this purpose please tick to say how you would like us to contact you: PostEmailTelephoneText message By sending this form, you agree to act in accordance with GAIN volunteering, data protection and safeguarding policy [recaptcha]
