Volunteers in Partnership

Application form for a VIP role

Please complete this form and return to the Volunteers in Partnership office at the address below. If you have queries or wish to discuss this further please contact the Volunteer Coordinator. The information given in this form is confidential to Cornwall Partnership NHS Foundation Trust and the individuals specifically focused on the identification of volunteer opportunties. Please give as much information about yourself as possible, as well as areas of the Trust that interest you, so that we are able to match you with a potential placement.
Mr/Mrs/Miss/Ms/
Other / First name(s): / Surname:
Previous surnames
Address
Post code: / Do you have a current driving licence Yes/No
Do have access to a car? Yes/No
Email address
Date of birth: / Telephone number:
Home
Mobile
Work
National insurance number / How would you prefer to be contacted?
Present occupation/employment
Name and address of employer/placement / Description of role / Date started
Previous occupation/employment – please provide full details for the last 10 years
Name and address of employer/placement / Description of role / Dates to/from / Reason for leaving
Current/previous volunteering experience
Name and address of employer/placement / Description of role / Dates to/from / Reason for leaving
Qualifications - please list below all your qualifications
Qualification and level / Awarding body / Date
Training – please list below all training you have undertaken
Training course / Provided by / Date
Interests – please tell us about your interests and hobbies
Please provide details of two people who are not relatives and who know you well (preferably employers) who would provide references. If you are employed or working as a volunteer one reference should be from that organisation. References may be taken up before you are invited to attend an interview.
Name
Telephone number
Address
Email address
How do you know them ? / Name
Telephone number
Address
Email address
How do you know them?
Declaration
A criminal records bureau and occupational health check are required for all volunteers. A returned check showing information relating to past offence or health problems does not automatically preclude you from volunteering and we will work with you to try and find a safe, enjoyable and fulfilling opportunity.
The information you provide will be processed in accordance with the Data Protection Act and will only be used for the purpose of this application.
Equality Act 2010
Is there any disability or health issue that we need to take into consideration in relation to this post?
Would you require any reasonable adjustments to be made in order to undertake the duties of a volunteering post? If yes, please give details below. / Yes/No
Yes/No
If you have answered yes to either of the questions above please give full details here
Information about criminal offences
Those working as volunteers in the NHS are exempt from the rehabilitation of offenders act 1975. This means that you must tell us about all criminal convictions, cautions or bind-overs including those that would otherwise be ‘spent’. You do not need to tell us about parking offences. You must inform us immediately if you are charged with an offence in the United Kingdom or in any other country.
Have you ever been charged or convicted of any criminal offence, been issued with a police caution, final warning or reprimand or are subject to any pending criminal proceedings in the UK or in another country? / Yes/No
Have you ever been subject to a police investigation, in the UK or in any other country, or have been dismissed by reason of misconduct from any previous employment, office or other position or have been the subject of an investigation by your employer or any other party in respect of theft, fraud, assault or any matter of conduct? / Yes/No
Have you ever been disqualified from the practice of a profession or been required to practice subject to specific limitations following fitness to practice proceedings or currently the subject of an investigation by a regulatory or licensing body in the United Kingdom or in any other country? / Yes/No
If you have answered yes to any of the questions above please give full details here
Declaration
I understand that the Trust will need my permission to proceed with checks in accordance with Home Office guidelines.
I declare that the details I have given are true and I know of no health reasons which could prevent me from undertaking a VIP role with the Trust.
I understand that it will not be possible to find placements for everyone and that any registration of a VIP will be subject to the completion of relevant checks and an informal interview.
I agree to my referees being approached prior to interview.
I understand and that failing to provide you will all relevant information or providing false or misleading information may result in my application being rejected, or if I am appointed my role may be terminated.
Signed: / Dated:

Please return this form to

Volunteer Co-ordinator

The Engineers House

c/o Shaw House

Porthpean Road

St Austell

PL26 6AD

Telephone 01726 873253

Email:


MONITORING INFORMATION

This section of the application form will be detached from your application form. The information collected will only be used for monitoring purposes in an anonymised format and will help the organisation analyse the profile and make up of applicants and appointees to jobs in support of their equal opportunities policies.

NHS Organisations recognise and actively promote the benefits of a diverse workforce and are committed to treating all employees with dignity and respect regardless of race, gender, disability, age, sexual orientation, religion or belief. We therefore welcome applications from all sections of the community.

* Date of Birth
* Gender / ¨ Male
¨ Female
¨ I do not wish to disclose this

Race relations (Amendment) Act 2000

* I would describe my ethnic origin as:
Asian or Asian British
¨ Bangladeshi
¨ Indian
¨ Pakistani
¨ Any other Asian background
Black or Black British
¨ African
¨ Caribbean
¨ Any other Black background / Mixed
¨ White & Asian
¨ White & Black African
¨ White & Black Caribbean
¨ Any other mixed background
White
¨ British
¨ Irish
¨ Any other White background / Other Ethnic Group
¨ Chinese
¨ Any other ethnic group
¨ I do not wish to disclose this

Employment Equality Regulations 2003

* Please select the option which best describes your sexual orientation
¨ Lesbian
¨ Gay
¨ Bisexual / ¨ Heterosexual
¨ I do not wish to disclose this
* Please indicate your religion or belief
¨ Atheism
¨ Buddhism
¨ Christianity
¨ Islam / ¨ Jainism
¨ Sikhism
¨ Judaism / ¨ Hinduism
¨ Other
¨ I do not wish to disclose this
Volunteeers in Partnership – Application form V001 / Page 1 of 6