Please complete all sections and return to Volunteer Services Team, St Helena Hospice, Unit 1 The Atrium, Phoenix Square, Wyncolls Road, Colchester, Essex CO4 9AS or email

YOUR DETAILS

TITLE / Forename / Surname / Known As
HOME ADDRESS
POSTCODE
TELEPHONE NO’s / Home / Mobile / Work
EMAIL ADDRESS

ROLE - Please select the role/s you wish to apply for

Please note that some roles require specific training and/or qualifications or a DBS check

AVAILABILITY- Please tell us when you are available to volunteer

DAY / MORNING / AFTERNOON / EVENING
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Are you currently in paid employmentYes please complete details belowNo 

Job Role
Organisation
Full or part time

HEALTH & WELLBEING

We rely on our Volunteers being medically fit to fulfil their duties. If you are in any doubt please check with your doctor. If you are applying for a driver role, you will be asked to complete another medical form following an informal interview.

It is also the policy of St Helena Hospice that we cannot accept volunteers in some patient related roles, who have suffered a recent bereavement; however there may be other roles available for you.

Please answer the following questions.

Are you in good health? / No  Yes 
Do you have any problems being on your feet continuously for between 2 to 4 hours? / No  Yes Please give details
Do you have any respiratory problems? / No  Yes Please give details
Do you suffer from epilepsy, dizziness or blackouts? / No  Yes Please give details
Do you suffer from heart problems or high blood pressure? / No  Yes Please give details
Do you, or have you in the past, suffered from any back problems? / No  Yes Please give details
Do you have vision impairments not corrected by glasses/contact lenses? / No  Yes Please give details
Are you registered disabled? / No  Yes Please give details
If you have answered yes to any of the above, please use this space to give us any additional information about how you think your health will affect your volunteering role.
Have you suffered bereavement in the last 12 months? No  Yes 
If yes, please confirm the following:
Relationship to you______Date of the bereavement______
Please use this space if there is any additional information you would like to share about your bereavement

EMERGENCY CONTACT DETAILS - Please complete details for anyone we can contact in the event of an emergency while you are volunteering at St Helena Hospice.

TITLE / Forename / Surname / Relationship to you
HOME ADDRESS
IncPostode
TELEPHONE NO’s / Home / Mobile / Work
EMAIL ADDRESS
TITLE / Forename / Surname / Relationship to you
HOME ADDRESS
IncPostode
TELEPHONE NO’s / Home / Mobile / Work
EMAIL ADDRESS

REFERENCES - Please give details of two people who have known you for at least two years. Referees must be over 18 years of age and must not be relations or spouse.

TITLE / Forename / Surname / Length of time known
HOME ADDRESS
IncPostode / Known in what capacity
TELEPHONE NO’s / Home / Mobile / Work
EMAIL ADDRESS
TITLE / Forename / Surname / Length of time known
HOME ADDRESS
IncPostode / Known in what capacity
TELEPHONE NO’s / Home / Mobile / Work
EMAIL ADDRESS

1 | PageVol App Nov 2017