VOLUNTEER APPLICATION FORM

SLIGO REGIONAL HOSPITAL

PERSONAL DETAILS
Surname: / First Name:
Address:
Email address:
Date of Birth:
Telephone Home: Mobile:
Occupation:
Next of Kin:
ADDITIONAL INFORMATION
Why have you chosen to work as a Volunteer at Sligo Regional Hospital?
Have you any experience working in a Hospital environment?
Please outline your preference in relation to area of work? (Tick all that apply)
SRH Volunteer Meet & Greet Service

Volunteer as a lay member on a hospital group/committee
What skills, experience and attributes do you feel you can bring to this role?
Do you have any medical condition or illness that might affect your work as a volunteer?
Yes No
If yes, please give details:
How did you hear about us?
Sligo Hospital Website  Work Colleague  Sligo Volunteer Centre 
Word of mouth  Internet Search  Volunteers in Hospital  Family/Friend  Other 
If other, please specify ______
AVAILABILITY
Which day(s) are most suitable for you? (Tick all that apply)
Mon  Tues  Wed  Thurs  Fri 
MORNING/AFTERNOON (enter most suitable time(s)
REFERENCES
Please give names and details of two referees. We retain the right to contact all previous employers.
I certify that the information on this application form is correct and may be checked as required including Garda clearance.
Reference (1)
Name:
Job Title:
Professional Relationship to candidate:
Dates of Employment (if applicable): From: To:
Postal Address:
Telephone Contact Details:
Email Address:
Reference (2)
Name:
Job Title:
Professional Relationship to candidate:
Dates of Employment (if applicable): From: To:
Postal Address:
Telephone Contact Details:
Email Address:
DECLARATION
I declare that to the best of my knowledge and belief, there is nothing in relation to my conduct, character or personal background of any nature that would adversely affect the position of trust in which I would be placed by virtue of the appointment as Volunteer at Sligo Regional Hospital.
Signed: / Date:

Please return completed application form (and Curriculum Vitae if available)

to Quality & Safety Department, Sligo Regional Hospital

Aug ‘14

Mission Statement

Sligo Regional Hospital is committed to the delivery of a high quality, patient centred service in a safe, equitable and efficient manner.

We recognise and value the contribution of each staff member and endeavour to support them in their ongoing development.