VOLUNTEER APPLICATION FORM

Confidential

Volunteer position and location applied for:
Mr/Mrs/Miss/Ms / Surname: / First name: / Known as:
Home address:
Postcode:
Email address:
Telephone number / Home: / Work: / Mobile:
Skills & Experience What skills or experience could you bring to St Helena Hospice? Please 
Administration / Fundraising / Nursing/Health Care/Clinical
Arts and crafts / Hairdressing/Beauty / Public Speaking
Banking/Accounts / HR/Recruitment / Reception
Catering / Information Technology / Retail/Sales
Driver / Legal work / Other (please list below)
Education/Training / Maintenance/Domestic
Event Organising / Marketing/Design
Please detail your availability i.e. days and hours per week available:
Unfortunately it is Hospice Policy that we cannot accept volunteers who have suffered a loss within the past twelve months and wishing to work in a patient area. However other roles may be available. Please give details if you have been bereaved within the last year.
What is your occupation present/past?
Please state why you are interested in becoming a volunteer for St Helena Hospice.
References (Please state below two referees. Referees should be over 18, not a relative and have been known to you for least two years).
*Please tick box if you do not wish us to contact referees at this stage.
Name: *
Occupation:
Address:
Postcode:
Tel No:
Email: / Name: *
Occupation:
Address:
Postcode:
Tel No:
Email:
Applicants are asked to complete the health questions below:
  1. Do you have any respiratory problems? YES/NO

  1. Do you suffer from epilepsy, dizziness or blackouts? YES/NO

  1. Do you suffer from heart problems or high blood pressure? YES/NO

  1. Do you, or have you in the past, suffered from back problems? YES/NO

  1. Do you have vision impairments which are not corrected by visual aids (i.e. glasses) YES/NO

  1. Are you registered disabled? YES/NO

  1. Do you consider yourself in good health to volunteer at St Helena Hospice? YES/NO

Emergency Contact Details
Please complete this section so we have details of who to contact if you are taken ill whilst volunteering. If you prefer you may give details of a close friend/ neighbour rather than a family member.)
Name:…………………………………………………………………………………………….…….
Relationship to you:………………………………………………………………………………………
Address:………………………………………………………………………………………………
Postcode:……………………………………………………………………………………………....
Home telephone number:…………………………….. Mobile number:……………………….
Name:………………………………………………….……………………………………………….
Relationship to you:…………………………………………………………………………..………….
Address:………………………………………………………………………………………………
Postcode:………………………………………………………………………………..…………..
Home telephone number:……………………………….. Mobile number: …………………….
Do you have any convictions involving theft, deception, dishonesty or any other? (If accepted as a volunteer, you will be required to complete a Disclosure & Barring Service form before commencing in a patient area)
A criminal record WILL NOT automatically bar you from becoming a volunteer. Any information given will be completely confidential.
All applicants to complete this declaration:
Are you legally eligible for a volunteering role in the UK? YES/NO
If you are legally eligible to work in the UK, you are eligible to volunteer. However, people from outside the European Economic Area may need permission to undertake voluntary work. If in doubt, please contact the Volunteer Team to discuss your situation.
I hereby sign to the best of my knowledge that the above information is correct, and I understand that if I am accepted as a volunteer my details will be held on a secure database for the hospice use only.
Signature…………………………………….… Date………………………………………………..

Please return your completed application form to:-

HR - Volunteer Team

St Helena Hospice, Unit 4, The Atrium, Phoenix Square, Wyncolls Road, Colchester. CO4 9AS

01206 931466

St Helena Hospice

Marketing Preferences

Name of Volunteer:
Volunteer Role:
Department / Shop:

KEEPING IN TOUCH

For administration purposes your details will be held securely on our Hospice databases in accordance with the Data Protection Act 1998. You will automatically receive communication from us relating to your volunteering activities; in addition we would like to contact you to ask and inform you about other ways to support the Hospice.

Please mark your preference by ticking as appropriate.

Please do not send me mail

Please do not telephone me

Please send me SMS (Text)

Please send me emails*

*Please confirm your email address ______

Wherever possible we will send communications electronically as this helps to save money on printing and postage costs.

From time to time we may need to check with you to make sure you are still happy to be contacted in the same way you have chosen.

If you decide to leave the Hospice, we will ask you if you are still happy for us to contact you via the communication methods you have chosen above.

Thank you for your interest in our work.

Signed ……………………………………Date ……………………..

Please return your completed application form to:-

HR - Volunteer Team

St Helena Hospice, Unit 4, The Atrium, Phoenix Square, Wyncolls Road, Colchester. CO4 9AS

01206 931466

St Helena Hospice

Equal Opportunities Monitoring

Name of Volunteer:
Volunteer Role:
Department / Shop:
Date:

We are highly committed to selecting volunteers solely on the basis of their ability to do the role for which they are being recruited, regardless of disability, race, gender, gender reassignment, health, social class, sexual preference/orientation, marital status, nationality, religion, employment status, age, membership or non-membership of Trade Union. A full copy of our Equal Opportunities policy is available on request. Please help us to monitor the implementation of this policy by completing and returning this form. This form will be detached from your application and will be used for monitoring purposes only.

Where did you first learn about this job?Please 

Through a newspaper/ journal advertisement?(please specify paper)
Through a friend?
Through being a volunteer?
Through the internet?
Other (please specify)

Sex

Are you Male or Female?

Age RangePlease 

20 or younger
21- 30
31- 40
41- 50
51- 60
61 or over

Disability

The 2010 Equality Act defines disability as ‘a physical or mental impairment which has a substantial and long-term negative effect on your ability to carry out your normal daily activities’. Disability can include conditions such as chronic back pain, diabetes, and repetitive strain injury or work related upper limb disorder.

Do you regard yourself as having a disability? (Yes/No)

Ethnic Origin

These figures are primarily used to monitor whether we treat people from all ethnic origins fairly. Ethnic origin questions are not about nationality, place of birth or citizenship. They are about colour and broad ethnic group- for example; UK citizens can belong to any of the groups indicated. The categories we use are those recommended by the commission for Racial Equality as they allow us to use census figures as a benchmark against which to compare. (Please the one box that MOST describes you).

White
Black-African
Black-Caribbean
Black-Other
Bangladeshi
Chinese
Indian
Pakistani
Other (please specify)

If you wish to provide more details about your ethnic origin please specify below:

Africa (excluding North Africa)
Asia
Caribbean
Central and South America
Eastern Europe
Middle East/North Africa
North America
Pacific (including Australia/New Zealand
Western Europe (excluding the UK)
UK
Other (please specify)

Please return your completed form to:-

HR - Volunteer Team

St Helena Hospice, Unit 4, The Atrium, Phoenix Square, Wyncolls Road, Colchester. CO4 9AS

01206 931466