Rowans Hospice Application Form
Post applied for:1. Personal Details
Surname (Mr/Mrs/Miss/Ms) / Forename:
Address:
Tel No: (Home)
(Work )
(Mobile)
Post Code: / Email Address:
Do you have a current clean driving licence?
Yes No / Do you own a vehicle?
Yes No
2. Education
School/College
F.E./University / Dates
From To / Subjects studied or Qualifications gained / Grade / Date
Obtained
3. Professional/Technical Qualifications or Membership
Professional Body or Training Establishment / Dates
From To / Qualification or Grade Membership / Registration
Enrolment Number
4. Employment/Volunteering Details
Employer/
Volunteer organisation
(Most recent First) / Position Held / Dates
From To / Salary/Grade / Reason for
Leaving
5. References
Please provide details of TWO REFEREES known to you professionally, one of whom should be your current employer/volunteer organisation where applicable.
School leavers: Please provide name of Head Teacher/Tutor:
Volunteers: If you are unable to provide a professional referee, please provide two character referees.
Name: / Name:
Address: / Address:
Tel No: Mobile No: / Tel No: Mobile No:
Position: / Position:
Email: / Email:
6. Experience
Please provide a summary of your previous experience and all other relevant information in line with the person specification, or Volunteer Role Guide, as to why you feel you are suitable for this position.
Continue on separate sheet if required.
Where did you see this position advertised? Website Newsletter Other
If other, please provide details:
______
Have you applied for a position at The Rowans Hospice in the past? Yes No
If yes, please state position and approximate date of application:
______
Are you related to an employee or Volunteer of The Rowans Hospice Group? Yes No
If yes, please state their name and relationship to you:
7. Criminal Convictions
Owing to the vulnerability of people receiving health care, all employee and Volunteer roles are exempt from the provisions of Section 4 (2) of the Rehabilitation of Offenders Act. Details of any criminal convictions you may have should therefore be stated below. Failure to disclose this information will result in action being taken.
The information provided on this form will be entered on to a computer and will be held in a secure and confidential manner under the terms and conditions of the DATA PROTECTION ACT 1984.
Declaration
I declare that the information I have given on this form is, to the best of my knowledge, true and complete. I understand that if it is subsequently discovered any statement is false or misleading, or that I have withheld relevant information, my application may be disqualified or, if I have already been appointed, I may be dismissed.
I hereby give my consent to the Company processing the data supplied on this application form for the purpose of recruitment and selection. I accept that if my application is successful, this application form will form part of my Personnel file and, in that case, I consent to the data on it being processed for all purposes in connection with my employment.
Signed: …………………………………………………. Date: …………………………………………………………
8. Volunteer Positions Only (Please tick your areas of interest):
Ward ( )
Fundraising/Events ( )
Fundraising/Clerical ( )
Driving – Patients ( )
Day Care ( )
Heath Centre ( )
Living Well Centre ( )
PAT Dogs ( )
Clerical ( )
Visitors Reception ( )
Patient Reception ( )
Phone Reception ( )
Gardening ( )
Coffee Shop ( )
Flower Room ( ) / Meerkats * ( )
Hospice Companion * ( )
Veterans Companion ( )
Bereavement Volunteer * ( )
Trading Company:
Sales Assistants ( )
Warehouse ( )
Van Driver/Porter ( )
Qualifications required for the following roles:
Hairdresser /Barber ( )
Manicurist ( )
Podiatrist ( )
Complementary Therapy ( )
* Training Provided
9. Volunteer Positions Only (Please provide your availability below):
Day / AM / PM / Eve / Day / AM / PM / Eve
Monday / Friday
Tuesday / Saturday
Wednesday / Sunday
Thursday / Bank Holiday
Rowans Hospice, Purbrook Heath Road, Waterlooville, Hants, PO7 5RU
1
Registered Charity No. 299731