PRIVATE & CONFIDENTIAL

VOLUNTEER APPLICATION FORM

Hospice of the Good Shepherd, Gordon Lane, Backford, Nr Chester

CH2 4DG

IF YOU REQUIRE THIS FORM IN A LARGE PRINT FORMAT PLEASE CONTACT THE VOLUNTEER COORDINATOR ON 01244 851091

NAME:
ADDRESS
POSTCODE:
E-MAIL ADDRESS:
CONTACT NUMBERS:
HOME:
MOBILE:
EMERGENCY CONTACT
NAME:
RELATIONSHIP
PHONE NUMBER

Please return to the Volunteer Coordinator at the above address or to the Shop Manager in any Hospice of the Good Shepherd shop.


TRANSPORT

Do you have a driving licence? Yes ( ) No (

Do you have your own transport? Yes ( ) No ( )

If no, how will you travel to the Hospice/Shop?______

AVAILABILITY

It is helpful to know when you may be able to help, volunteering roles usually only require you to attend once per week or fortnight. It is therefore useful to have an idea of your general availability in order to successfully fit you into the voluntary team

Please tick as appropriate

Morning / Afternoon / Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Are you available at short notice? If so when and how could you be contacted?

______

Which area of voluntary work do you feel you would enjoy and would utilise your skills? (E.g. Driving,Flower Arranging,Fundraising, Gardening,Non-Nursing tasks on the Ward and in Day Care,Reception, Shops.

Would you be happy to be contacted occasionally if the Fundraising team require support?

Event Support e.g. Marshalling, Refreshments, Registrations Yes( ) No( )

Promotions and Selling e.g. Raffle Tickets, EventsYes( ) No( )

Collection Box Agent – handing out and collecting boxes Yes( ) No( )

Leaflet and Poster DistributionYes( ) No( )

Bag PackingYes( ) No( )

RELEVANT EXPERIENCE / SKILLS

Please mention below any qualifications, experience, skills or hobbies that you feel may be relevant to your application to be a volunteer.

If you are currently employed, what hours do you work?

REASONS FOR VOLUNTEERING

Please describe briefly your reasons for wishing to volunteer and why you have chosen the Hospice of the Good Shepherd.

Have you experienced any deaths among members of your family or close friends during the past two years?

If so please give brief details:

Is there anything else you feel we need to know?

REFEREES

Please give the names and addresses of two people, who you know well but are not related to you, whom we may approach for a character reference.

Name:
Address:
Postcode:
Phone number:
Email address:

REHABILITATION OF OFFENDERS

Volunteers should note that the Hospice is exempt from the provisions of section 4 (2) of the Rehabilitation of Offenders Act 1974. This means that Hospice based volunteers are not entitled to withhold information about convictions which, for other persons, are ‘Spent’ under the provisions of the Act. All volunteers based at the Hospice are required to complete a Criminal Records Bureau Disclosure Form. Any information given will be completely confidential, and will only be used in determining whether a particular voluntary placement is appropriate.

Do you have any criminal convictions? Yes ( ) No ( )

If yes please give brief details

DECLARATION

I confirm that the above information is complete and correct. I agree to be enrolled as a Volunteer and to abide by the Rules concerning the duties of volunteers. I also understand that I must hold in strict confidence any personal information concerning patients and staff which may become known to me during the exercise of my voluntary duties.

The information on this form will remain confidential and will be used for the purpose of selection. If your application is successful we may wish to process this information for personnel administration and business management purposes. This will be in accordance with Data Protection Act 1998. By signing this form you are giving your consent to these uses.

Signed: ______Date: ______