Freedom From Torture West Midlands
Unit 5, 1st Floor,Caroline Point, 62 Caroline Street, Birmingham, B3 1UF
Telephone: 0121 314 6825
Email:
Freedom from Torture is the working name of the Medical Foundation for the Care of Victims of Torture - a registered charity in England 1000340 andScotland SC039632 red charity
Please complete this form and return it to Gilberte Hanania, HR Administrator at the above email address.
VOLUNTEER APPLICATION FORM FOR DOCTORS
WITHIN THE MEDICAL FOUNDATION MEDICO LEGAL REPORT SERVICE AT FREEDOM FROM TORTURE
Name......
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Home address......
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Work address......
Telephone numbers
Home ......
Work ......
May we contact you at work? Yes...... No ......
E-mail address......
Professional qualifications (approx. 5 lines):
Previous appointments (approx. 15 lines):......
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Current (or most recent) employment:
Job title: ......
Name of organisation......
Date started......
Date left: ......
Please provide a brief summary of main duties & responsibilities:
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Relevant experience working with those suffering from personal and social trauma (approx. 7 lines):
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Memberships of professional associations or learned bodies:
(please include whether any of these associations/bodies are members of umbrella professional bodies, and if so, give details of this body):
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Professional training ......
Publications and research ......
What languages do you speak? (please list)
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How much time can you offer to Freedom from Torture?
(Indicate by typing a capital ‘X’ next to the appropriate session. Then below this write what days and times you are available)
Days and Times available......
Regular weekly sessions......
Regular fortnightly sessions......
Please describe the nature of the work you are offering (approx. 10 lines):
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If you have professional insurance, please give details of insurance companies and registration number:......
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Have you ever been convicted of a criminal offence?
If so, please give details below: ……………………………………………………………….
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Do you have a DBSs (Disclosure & Barring Service, previously known as CRB (Criminal Record bureau Disclosure form) issued less than 6 months ago? Is it an enhanced one? ………………
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If you do not have a DBS, we will conduct one; please note there is no portability in DBS.
How did you first learn about the work of Freedom from Torture?
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Please supply details of two referees (one of whom must be your current or most recent employer, a doctor or clinician):
First Referee:
Name......
Address:......
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Postcode: ......
Telephone number:......
E-mail Address:......
Relationship to Referee: ......
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Second Referee
Name: ......
Address:......
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Postcode: ......
Telephone number:......
E-mail Address......
Relationship to Referee: ......
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May we contact these referees immediately? Yes ...... No......
NBPlease include email addresses. Thank you.