LINDSEY LODGE HOSPICE

VOLUNTEER APPLICATION FORM

CONFIDENTIAL

Thank you for your interest in volunteering for Lindsey Lodge Hospice, we are delighted to welcome you.

Please complete the details below:


EMPLOYMENT STATUS

Not currently seeking employment: Yes/NoRetired from employment: Yes/No

Unemployed, but seeking employment: Yes/NoIn full/part time employment: Yes/No

Involved in training scheme: Yes/NoStudentYes/No

Other - Please give details…………………..……………………………………………………………………..…………………..

Health declaration and Equal Opportunities Monitoring: Confidential

HEALTH

Applications from people with disabilities are welcomed but, in terms of Health and Safety, it is important that the Hospice does not place you in the wrong role. In order to ascertain the most suitable role for you as a volunteer for the Hospice, certain information about your health is required.Do you consider yourself covered under the terms of the Disability Discrimination Act 1995? YES/NO

If YES, what is the nature of your disability? Please give details.

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(If preferred, continue on a separate sheet and attach it to this application form.)

Do you have any allergies or other health matters that the Hospice should be aware of e.g.:-

YES NODETAILS

a) Serious illness/operations
b) Skin disorders
c) Hearing/eyesight problems
d) Chest ailments
e) Heart/blood pressure problems
f) Diabetes
g) Back problems
h) Arthritis
i) Migraine
j) Epilepsy/blackouts
k) Nervous/psychiatric problems
l) Allergies
m)Other
It is important that you inform the Hospice should you suffer from any illness in the future that might affect your ability to volunteer for the organisation, or, that would put others at risk.
EQUAL OPPORTUNITIES
Equality of opportunity is important, and in order to be able to display a commitment to this belief, it is necessary to monitor all the relevant details of volunteer applications, including ethnicity, this information is for statistical purposes only.
White British. Black British  White Irish  Other White  Mixed White/Black Carribean Mixed White/Black African Other Black Mixed White/Asian Other Mixed  Indian  PakistanBangladeshi Other Asian  Chinese  Other Not Stated 
Other Please specify

GENERAL INFORMATION

Have you suffered a bereavement in the last 5 years? If ‘Yes’ please supply dates and details

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Details of skills/hobbies/interests.

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Details of past employment---who worked for, and in what capacity

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Will you please tell us why you are interested in volunteering for the hospice.

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What skills, knowledge and experience will you bring with you?

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REHABILITATION OF OFFENDERS ACT 1974

You are asked to note the following paragraph and provide any necessary information. Because of the nature of the work you are applying form, the post is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation of Offenders Act (Exceptions) Order, 1975. Applicants are, therefore, not entitled to withhold information about convictions which for other purposes are “spent” under the provisions of the Act, and, in the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action by the Hospice. Any information given will be completely confidential and will be considered only in relation to an application for the positions to which the Order applies.

Please tick the appropriate boxes below: YES NO

Are you currently the subject of any police investigation and/or prosecution in the UK or any other country?
Have you ever been convicted of any criminal offence required by the law to be disclosed, received a police caution in the UK or a criminal conviction in any other country?
Are you currently the subject of any investigation or proceedings by any body having regulatory functions in relation to health/social care professionals including such a regulatory body in another country?
Have you ever been disqualified from the practice of a professional required to practice it subject to specified limitations following a fitness to practice investigation by a regulatory body, in the UK or another country?

If you have answered “YES” to any question, please give details on a separate sheet, place in a sealed envelope and attach it to this application.

REFERENCES

It is the policy of Lindsey Lodge Hospice that volunteers require two satisfactory references before they join the organisation.Please supply the contact details of two referees’ below. A referee cannot be a future line manager or related to you by blood or marriage. If necessary, one referee can be a friend. The referees should be over 18 years of age and should preferably have some knowledge of you in a work capacity and known you for at least 2 years.

Referee 1.

Name……………………………………………………..Title………………………Relationship…..…..……………….…………

Address…………………………………………………………………………………………………………….…………………….………….

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PostCode………………….………………….. Tel no (inc Code)…………………………….……………………………..……..

Email address:………………………………………………………………………………………………….……………….……………..

Referee 2.

Name…………………………………….…………..Title………………………….Relationship……………….………...…………

Address……………………………………………………………………………………………………..…….………….…………………….

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Post Code………………….………………….. Tel no (inc Code)…………………………………..……….……………………..

Email address:……………………………………………………………………………………………………..…………….…………….

Lindsey Lodge Hospice operates a no smoking policy on all its premises.

(All information disclosed on this registration, will only be used in compliance with the Data Protection Act 1998).

DECLARATION

I wish to become a volunteer for the Lindsey Lodge Hospice, I agree that all information I have submitted within this application is true and accurate. I also agree to the two references being taken up.

Signature of applicant: -…………………………………………………………………………………………….…………

Date of application: - ……………………………………………….…………………………………………….……………

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Lindsey Lodge Hospice

Burringham Road

Scunthorpe DN17 2AA

Contact: Nerissa Gallagher, Volunteer Services Manager or 01724 270835

June 2016