CLAN PEER MENTOR VOLUNTEER APPLICATION FORM

Application Date: _____________________

Personal Details
Name
Address

Phone Number:
Email address
Preferred method of contact
Our volunteering specifies that applicants must be
living independently for at least one year. Do you
meet these criteria?
How did you hear about CLAN?

Phone:
Email:
Yes:
No:
Please specify type of housing (private rented/
family home/Council Housing): ______________
Crosscare Service:

Website:

Education course:

Friend/word of mouth:

Other:

CLAN hours are usually 10am 4pm Monday, Tuesday, Thursday,

Friday and until 8pm Wednesday evenings. There will occasionally be
weekend trips away.
Are there any days that
Monday

Tuesday

Wednesday
would not suit you to work?
Thursday

Friday

We ask for a commitment of

Yes
No
9 months to 1 year to the
project, at this point are you
able to give this time
commitment?

Availability

General Information
3.1: Why do you want to become a Peer Mentor volunteer with CLAN?
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What is your understanding of the role of a Peer mentor?

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Part of being a peer mentor is using your own personal experiences to guide your work with
people. Can you briefly expand on any personal experience of homelessness, addiction mental
health or support services you may have?
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In your own words please tell us what skills/ experience/ qualities would you bring to the role of
Peer Mentor
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Any other comments:
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Part of being a peer mentor is sharing your personal experience with CLAN members. Is there
anything you would have difficulty discussing with the person you will mentor?
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Health Declaration
Are you currently in good physical
health?
(please give any specific details
which you feel may be relevant)

Yes

No

Garda Vetting
Due to the nature of our work with vulnerable adults it will be necessary for all interns to complete a Garda vetting
form disclosing any past convictions. Please note that a previous criminal charges and convictions will not
necessarily disqualify you from your internship with us.
Do you have a criminal record or
Yes
No

any pending charges?

Are you willing to fully disclose the nature of these to your supervisor to comply with
Yes:
Garda vetting procedures?(all information will be kept confidential)
No:

Reference: Please supply us with the names of 2 Referees (not Relatives)

1. Name

2. Name

Address

Address

Email

Email

Telephone:

Telephone:

6. Declaration
I declare that the information given on this form is complete and correct to the best of my knowledge and that I
understand that inaccurate or false information given may result in an offer of internship being withdraw.
I agree to complete a Garda Vetting Form disclosing any past offences.
Signature:

Date:

Please post or return to:

Emer Morrissey,
Crosscare,
20-23 Arran Quay,
Dublin 7.
3

Or send by email to: emorrissey@crosscare.ie