CONFIDENTIAL

Please complete all sections in full, and submit a CV, if appropriate.

APPLICATION FOR THE ROLE OF

VOLUNTEER COMPLEMENTARY HEALTH PRACTITIONER

Title by which you would wish to be addressed……………………………

SURNAME:.…………………………………………………………………………

FORENAMES:………………………………………………………………………

ADDRESS:…………………………………………………………………………..

………………………………………………………….…………………………….

………………………………………………………………………………………..

………………………………………………………………………………………..

POSTCODE: ………………..

TEL.NO.Home:

Work:Mobile:

Email:

Person to Notify in Case of Emergency

Name:

Relationship:

Best Contact Phone:

Application No. (for internal use only)

PRIVATE AND CONFIDENTIAL

VOLUNTEER COMPLEMENTARY HEALTH PRACTITIONER TO WORK WITH THE COMPLEMENTARY HEALTH SERVICE

QUALIFICATIONS IN COMPLEMENTARY HEALTH

College, University etc / Date
From / Date
To / Qualifications gained (with grades) / Dates

OTHER RELEVANT QUALIFICATIONS

Qualification/Level/Part

ANY STUDIES BEING UNDERTAKEN

PROFESSIONAL MEMBERSHIPS, REGISTRATION AND INSURANCE

Organisation / Registration Number / Expiry/Renewal Date

Employment History

Current / Last Employer’s Name:Nature of Business:

Post Held:

From:To:

Brief outline of duties:

Employment prior to above over the last 20 years (most recent first)

Name & Address of previous employersPost heldFrom:To:

References

Please give names, addresses and telephone numbers of two referees (one must be your present or, if not currently working, your most recent employer and one should be complementary health related). NOTE: Referees, for shortlisted candidates, will be approached before interview unless you indicate otherwise by ticking the box provided. Weldmar Hospicecare Trust also reserves the right to contact any previous employer.

Referee 1: DO NOT CONTACTReferee 2: DO NOT CONTACT

NAME:NAME:

ADDRESS:ADDRESS:

TEL.NO:TEL.NO:

POSITION HELD:POSITION HELD:

REHABILITATION OF OFFENDERS ACT 1974

Have you any convictions or are currently the subject of police proceedings in this or any country?

As this post is exempt from the above act please give details of any convictions.

PROTECTION OF VULNERABLE ADULTS/PROTECTION OF CHILDREN ACT 1999

Are you or have you ever been the subject of any fitness to practice proceedings by a UK or overseas licensing or regulatory body?

Tick to confirm you have completed and enclosed Equal Opportunities Monitoring Form as your application will not be considered without this.

Where did you see this role advertised?

Are you a holder of a current driving licence:YES / NO

Do you have the use of a car?YES / NO

Do you have any current endorsements?YES / NO

I understand that any offer of voluntary work will be subject to the information on this form being true and correct.

I also understand that appointment will be subject to satisfactoryDisclosure & Barring Service clearance and references.

Signed:Date:

PLEASE INDICATE BELOW WHY YOU CONSIDER YOU WOULD BE SUITABLE FOR THIS ROLE-

REFERRING TO ANY RELEVANT SKILLS, EXPERIENCE AND ACHIEVEMENTS TO SUPPORT YOUR APPLICATION.

Returning this Application Form

Please return this form in an envelope marked “Private & Confidential” to:

Caroline Munslow

Volunteer Services Adviser

Weldmar Hospicecare

Hammick House

Bridport Road

Dorchester

DT1 3SD

Or e-mail to: