Applicationandregistrationtobecomeavolunteer
Strictlyconfidential
Ifyourequirehelptofillinthisform pleasecontactVolunteering Office
on 01785 783068
YourDetails
Name...... ……………………………………..
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Tel Number...... Mobileno......
E-mail......
Dateofbirth......
Yourvolunteering
Whattypeofvolunteering roles areyou interestedin?......
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Or
Whyareyouregisteringyourinterestin becomingavolunteeratthistrust?......
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Availability
Whenareyouavailabletovolunteer?Pleasetick thedaysandtimesthatapply.(This istoprovide anindicationofyouravailability,don’tworryif youarenotavailableatthesetimeseveryweek).
Day / Mornings / Afternoons / EveningsMon
Tues
Wed
Thurs
Fri
Sat
Sun
Yourinterestinvolunteering
Pleasegiveyourreasonsforapplyingtobea volunteer.Circleortickthe onewhichapplies toyou:
•togivesomethingbackafteryouorfamily havebenefitedfromNHSservices
•tosupportaparticularcause
•toexploreacareerinhealthcare
•tofillsparetime
•togainsomeworkexperience
•tomeetnewpeopleandmakenewfriends
•todevelopormaintainyourskillsand experience
•tohelpdeveloporimprovespecificservices
•forspiritualfulfillment
•tomaintainorimproveyourhealthand wellbeing
•other(pleasestate)......
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Doyouhaveanypreviousexperienceof volunteering,orareyoucurrentlyavolunteer? Pleasegivedetails......
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Otherinformation
Doyouhaveadrivinglicense?......
Doyou have access to a car?......
Disabilityinformation
Doyouconsideryourselftobedisabled?
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If yes, what supportoradjustments do you thinkyouwillneedtotakeupavolunteering postatthistrust?......
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Nationalityandimmigrationstatus
AreyouaUnitedKingdom(UK)orEuropean Community(EC)orEuropeanEconomicArea (EES)National?
■YES■NO
Non-EUnationals
Notallvisasallowyoutovolunteer.Please supplydetailsofanyvisacurrentlyheld, includingnumber,start/expirydateanddetails ofanyrestrictions.Pleaseconfirmthatthe visa allowsyoutovolunteer(ifindoubtyoushould checkwiththeUKBorderAgency)
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Anyotherinformationyouwouldliketoaddin supportofyourapplication,forexample hobbiesorinterests?......
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References
Pleasesupplydetailsoftworeferees.These can beyourcurrentemployer,teacher,tutorora communityleader,GP,youthworkerorsupport worker.Youmaynotusefamilymembersas referees.
Refereeone
Name...... ……………………………………..
Address...... ……………………………………
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Howlonghaveyouknownthisperson?......
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Refereetwo
Name...... ……………………………………..
Address...... ……………………………………
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...... Postcode...... Relationshiptoapplicant......
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Howlonghaveyouknownthisperson?......
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Importantinformation
Have you been in contact with anyone from the Trust regards volunteering?
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If yes, who and where do they work?
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Becauseofthe natureofvoluntaryhelpgivenin healthcare,exemptionunderthe Rehabilitation ofOffendersAct 1974applies;
Have you ever beenconvictedofanoffence?
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Ifyes, detailsoftheconvictionwillberequired andwillbetreatedinthestrictestconfidence. Pleasesupplydetails.
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Allvolunteerswillberequiredtocompletea DisclosureApplicationfortheDisclosure and
Barring Service.
YouwillalsobeaskedtocompletetheTrusts Occupational Health and Wellbeing which mayormaynot resultinyoubeingaskedtoseethe occupationalhealthdoctor.
Signature......
Date......
Data Protection Statement:
The Information you have provided and agreed to will be kept by the Trust and treated in the strictest.
It will not be shared with a third party without your explicit consent, unless we have a statutory obligation to do so.
If you require access to this information at any time you should ask the Volunteer Service Manager.
Pleasereturnthisformto:
Volunteers, Membership Manager
Freepost RLUS-GBES-KBYL
South Staffordshire and Shropshire Healthcare NHS Foundation Trust
Trust HQ
Corporation Street
Stafford
ST16 3SR